HOOVES Retreat Application
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Email *
How did you hear about HOOVES? *
I am a  *
Dates of Service (If applicable)
First Name *
Last Name *
Street Address *
City *
State *
Zipcode *
Phone Number *
Date of Birth *
MM
/
DD
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YYYY
Gender *
Ethnicity *
Relationship Status *
Religious Preference
Employment Status  *
Gross Annual Income Range *
Branch of Service  *
MOS/AFSC/Rate and Description
Dates of Service
Highest Rank Achieved
List of Deployments 
Were you injured or wounded during your military service?
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If you answered "Yes" to the above question, please provide a brief description of the nature of the injury below. If answered "No" proceed to the next question.
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Have you been diagnosed with a TBI (Traumatic Brain Injury)?
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Have you been hospitalized for psychiatric reasons? *
If yes, please explain
Have you received a psychiatric diagnosis from a behavioral health or medical professional after seeking their help?
 *
If yes, please list
Have you experienced any of the following? (Please check all that apply) *
Required
Do you have any medical diagnosis? *
If yes, please list diagnosis and date
Do you have a service-connected disability? *
If yes, please explain and list date of injury *
If you have a VA disability please list percentage *
Have you experienced thoughts of suicide within the past year?
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If you answered "Yes" to above, please provide brief explanation of when and what was going on in your life that contributed to your thoughts. If answered "No" to above, please proceed to next question.
Have you ever been hospitalized for psychiatric reasons?
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Have you ever attempted suicide? *
If yes please list date(s)
Are you currently under the care of a mental health or medical professional for your psychiatric condition(s) (e.g., psychologist, psychiatrist, social worker, primary care manager)? *
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If you answered "Yes" to above, please give the name of your provider and the nature of the treatments being received currently. If answered "No" to above, please proceed to next question.
Please list the names of any current prescription medications used and what you use them for (put N/A if you have none).
Are you currently dependent on alcohol or substances? *
If so, please list the substance and frequency of use.
Are you currently in, or have you ever been in treatment for alcohol or substance abuse?
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If you answered "Yes" to above, please provide brief details on circumstances surrounding treatment and approximate dates of treatment. If answered "No", please proceed to next question.
Please tell us your personal goals for attending the HOOVES program. What do you hope to achieve or accomplish in this program?
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Please describe what personal characteristics, relationships, work problems, or other issues are likely to be obstacles to your ability to implement changes to your daily life.
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List any food allergies or special accommodations needed. *
Is there anything else you feel that we should know?
Emergency Contact Name and Relationship *
Emergency Contact Phone Number *
Shirt Size *
Preferred Retreat Dates
To be eligible to attend a HOOVES retreat, you must agree to the following
 *
Required
I will not bring any weapons on the premises, including storing them in vehicles (examples include: guns, knives of any kind, sticks, mace, etc.).
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PARTICIPATION: In order to make sure that I receive the best results from my retreat experience, I understand that I must commit to being part of all training events, group sessions, and meals. I will not leave the premises or miss any scheduled classes during the retreat.

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I certify that my answers are true and complete to the best of my knowledge. By signing your full name, you are agreeing to the above policies and digitally signing this application.
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A copy of your responses will be emailed to the address you provided.
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