Military Related Counseling Contact Form
(PLEASE CHECK ALL THAT APPLY TO YOUR CURRENT SITUATION)
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Name: *
Contact Number: *
Contact Email: *
Are You and Your Family Members Willing/Wanting to Participate in Counseling? *
Are You and Your Family Experiencing Any of the Following:  (Please Answer All Areas of Concern) *
Yes
No
Adjustment to Killing
Adjustment to the Military Culture
Amputee/Loss of Mobility/Disfigurement
Anger Management or Domestic Violence
Antisocial Behavior in the Military
Anxiety
Attention and Concentration Deficits
Bereavement Due to Loss of a Comrade
Borderline Personality Disorder
Brief Reactive Psychotic Episode
Chronic Pain After Injury
Combat and Operational Stress Reaction
Conflict with Comrades
Depression
Diversity Acceptance
Financial Difficulties
Homesickness/Loneliness
Insomnia
Mild Traumatic Brain Injury
Nightmares
Opioid Dependance
Panic/Agoraphobia
Parenting Problems with Deployment
Performance-Enhancing Supplement Use
Phobia
Physiological Stress Response - Acute
Post-Deployment Reintegration Problems
Posttraumatic Stress Disorder (PTSD)
Pre-Deployment Stress
Separation and Divorce
Sexual Assault - By Service Member
Shift Work Sleep Disorder
Social Discomfort
Spiritual and Religious Issues
Substance Abuse/Dependence
Suicidal Ideation
Survivor's Guilt
Tobacco Use
What is You and Your Family's Preferred Availability? (PLEASE LIST DAYS & TIMES) *
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