PWHT Registration Form

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Please complete the form to the best of your ability. Leading up to the workshop, one of the workshop instructors will reach out to you for a brief pre-workshop interview to answer your questions and review your registration form with you. If you have any questions about the registration process, feel free to reach out to Leslye.moore@pwht.org THIS FORM AND YOUR RESPONSES ARE KEPT CONFIDENTIAL

Email *

ONLINE only Power Breath Meditation workshop, August 17 - 21, 2022. Wed - Fri 6:30 - 9:00pm, Sat & Sun 10:00am - 1:00pm Pacific Time. Teachers: Leslye Moore /

First Name *

Last Name *

Address

City *

State *

Zip

Home Phone

Cell Phone *

Emergency Contact & Phone *

Date of Birth (Must be at least 18 years old)

YYYY

Gender *

Participant Designation *

Branch of Military Service (only Veteran need respond)

Military Status

Deployment information (optional)

How did you hear about the course?

Briefly describe your mental and physical health *

Please indicate if you have any of these conditions: *

Asthma

Diabetes

Emphysema

seizures/Epilepsy

Heart Disease

Stroke

Bi-polar

High Blood Pressure

Depression

Anxiety / Panic disorder

Traumatic Brain Injury

Pregnancy

Post-Traumatic Stress

NONE

Other:

Required

If you are you presently under the care of a physician, or psychiatrist, or have been recently hospitalized, please describe :

Please list any health problems or recent health concerns (mark N/A if none): *

Please describe in detail medications you are taking:

Please list dates, course name and experiences with any meditation techniques or other self-development courses/techniques you have done

Agreement

It is compulsory to attend all sessions of the course. Taking notes and use of tape recorders is prohibited. Agreement: I understand that any benefits derived from this course depend upon the extent of my participation. I therefore accept full responsibility for the outcome and I willingly agree to follow all instructions and participate fully. I also agree that I will not disclose the content of this course to anyone. I further agree that I will not attempt to instruct others in any of the techniques used in the course until such time as I receive personal training from Project Welcome Home Troops or IAHV. By entering my name and date below I agree to the above.

Signature *

Today's Date *

YYYY

Military Stress Checklist (Veteran and military only - OPTIONAL)

Instructions: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully and click the appropriate bubble to indicate how much you have been bothered by that problem in the last month. Please use the following scale: Not at all (1) A little bit (2) Moderately(3) Quite a bit(4) Extremely(5)

Repeated, disturbing memories, thoughts or images of a stressful military experience form the past?

Not at all

Extremely

Clear selection

Relapsed, disturbing dreams of a stressful military experience from the past?

Not at all

Extremely

Clear selection

Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?

Not at all

Extremely

Clear selection

Feeling very upset when something reminded you of a stressful military experience from the past?

Not at all

Extremely

Clear selection

Having physical reactions (e.g. heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience from the past?

Not at all

Extremely

Clear selection

Avoid thinking about or talking about a stressful military experience from the past or avoid having feelings related to it?

Not at all

Extremely

Clear selection

Avoid activities or situations because they remind you of a stressful military experience from the past?

Not at all

Extremely

Clear selection

Trouble remembering important parts of a stressful military experience from the past?

Not at all

Extremely

Clear selection

Loss of interest in things that you used to enjoy?

Not at all

Extremely

Clear selection

Feeling distant or cut off from other people

Not at all

Extremely

Clear selection

Feeling emotionally numb or being unable to have loving feelings for those close to you?

Not at all

Extremely

Clear selection

Feeling as if your future will somehow be cut short?

Not at all

Extremely

Clear selection

Trouble falling or staying asleep?

Not at all

Extremely

Clear selection

Feeling irritable or having angry outbursts?

Not at all

Extremely

Clear selection

Having difficulty concentrating?

Not at all

Extremely

Clear selection

Being “super alert” or watchful on guard?

Not at all

Extremely

Clear selection

Feeling jumpy or easily startled?

Not at all

Extremely

Clear selection

A copy of your responses will be emailed to the address you provided.

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