Veteran Participant Application

Are you a veteran of the US Armed Forces?

Yes

No

Under which branch of the US Armed Forces did you serve?

Army

Navy

Air Force

Marines

Coast Guard

Army National Guard

Air National Guard

Space Force

Which form of veteran ID can you provide to verify your veteran status?

DD-214 Form

DoD ID Card

Veteran ID Card (VIC)

Upload copy of your veteran ID (DD-214 Form, DoD ID Card, Veteran ID Card)

Email

Name

Phone

Street Address/City/State/Zip

County

Washington

St. Croix

Pierce

Chisago

Isanti

Anoka

Ramsey

Hennepin

Sherburne

Wright

Carver

Scott

Dakota

Polk

Dunn

Pepin

Other

Date of Birth (YYYY-MM-DD)

How did you hear about us?

Do you have any prior experience with horses? If yes, please tell us more.

Please share with us what you hope to gain from this experience.

Please indicate any areas you may experience difficulty, have limitations, or may require assistance.

hearing loss

vision loss

loss of mobility or impaired movement

seizures

spinal injuries

balance and/or coordination

pregnancy

heart conditions (such as arrythmia, high blood pressure or heart disease)

diabetes

cognitive deficits (difficulty focusing or following instructions)

None of the Above

Please share with us a little about yourself.

In your own words, please share with us any current mental health challenges you are facing.

How long have you been experiencing these mental health challenges?

Less than 1 year

1-2 years

2-4 years

5 years or more

In the past, what have you done to cope with or improve your mental health challenges? Was it helpful?

What types of symptoms have you experienced in the last 30 days?

Difficulty falling asleep

Difficulty getting out of bed to begin the day

Loss of interest in previously enjoyed activities

Withdrawing from friends and family

Depressed mood

Rapid mood changes

Anxiety

Feelings of Guilt

Fear of certain objects or situations

Outbursts of anger

Spending increased time alone

Feeling numb

Irritability

Panic attacks

Feelings of worthlessness or hopelessness

Feeling or acting like a different person

Changes in eating, appetite, weight gain or loss

Voluntary vomiting

Self harm or self-mutilation/cutting

Thoughts about harming someone else

Suicidal ideation

Intrusive memories or flashbacks

Racing thoughts

Difficulty thinking or concentrating

Inability to decipher what is real and not real

Unusual visual experiences such as flashes of light, shadows or hallucinations

Concerns about sexuality or sexual orientation

Difficulty problem solving

Sense of being out of control

None of the Above

What kinds of stress factors have you experienced in the last 2 years?

Loss of job(s)

Loss of important relationship(s)

Death of close friend(s) or family member(s)

Significant illness or injury of close friend(s) or family member(s)

Significant financial loss or debt

Losing a home

Moving to a new community

Victim of domestic violence

Witness to traumatic event(s)

Significant illness or injury

Partial loss of mobility, strength or function due to illness or injury

Child custody dispute(s)

Legal/court/criminal dispute(s)

None of the above

Have you seen a counselor, psychologist, psychiatrist or any other mental health professional before?

Yes

No

If you answered yes, please provide the name of the therapist(s), the reason(s) for seeking help, and the approximate date(s) of treatment.

Are you currently taking any psychiatric medication?

Yes

No

If you answered yes, please provide the name of the medication(s), dosage, duration you have been using the medication, and if the medication is helpful.

Have you ever been hospitalized for psychiatric reasons?

Yes

No

If you answered yes, please provide the reason and the approximate date(s) of hospitalization.

Have you ever attempted suicide?

Yes

No

If you answered yes, please tell us more about that. Please include approximate number of attempts along with approximate dates and circumstances surrounding them.

Are you CURRENTLY under treatment for any medical condition?

Yes

No

If you answered yes, please tell us more about that.

What kind of social activities do you participate in? How often do you participate in these activities?

Have you been arrested?

Yes

No

If yes, please explain.

Do you have a history of alcohol abuse?

Yes

No

If yes, how long ago or at what age did you begin abusing alcohol?

About how many drinks do you usually have per week?

I don't drink

Less than 3

4-10

More than 10

How often does drinking alcohol negatively affect your relationships with friends and family?

Never

Sometimes

Most of the time

All the time

If you start drinking, how difficult do you find it to stop?

Not Difficult

Somewhat Difficult

Difficult

Very Difficult

Do you have a history of drug use?

Yes

No

What types of drugs (not including drugs that were prescribed to you) are you using currently or have used in the past? Select all that apply.

Cannabis/Marijuana'Cannabis/Marijuana

Depressants

Cocaine or crack

Fentanyl

Heroin

Inhalants

Ketamine

LSD or acid

MDMA/ecstasy

Mescaline/peyote

Methamphetamine

Opioids/Oxy/Percs

PCP/angel dust

Speed

Psilocybin/mushrooms

Rohypnol/flunitrazopam/roofies

Steroids (anabolic)

Synthetic cathinones/bath salts/flakka

Other

None of the Above

If you checked any of the drugs listed above, please tell us more about your age when you started using each drug, and how long it has been since the last time you used the drug.

If you are currently using drugs, please describe your drug use in the last 30 days.

Please share with us anything else you would like us to know about you.

Which Course Dates are you interested in?

6 PM - 8 PM Tuesdays - July 8, 15, 22, 29

6 PM - 8 PM Tuesdays - August 5, 12, 19, 26

6 PM - 8 PM Tuesdays - September 2, 9, 16, 23

6 PM - 8 PM Tuesdays - September 30, October 7, 14, 21

Veteran Participant Application

Are you a veteran of the US Armed Forces?

Under which branch of the US Armed Forces did you serve?

Which form of veteran ID can you provide to verify your veteran status?

County

Please indicate any areas you may experience difficulty, have limitations, or may require assistance.

MENTAL HEALTH QUESTIONNAIRE

How long have you been experiencing these mental health challenges?

What types of symptoms have you experienced in the last 30 days?

What kinds of stress factors have you experienced in the last 2 years?

Have you seen a counselor, psychologist, psychiatrist or any other mental health professional before?

Are you currently taking any psychiatric medication?

Have you ever been hospitalized for psychiatric reasons?

Have you ever attempted suicide?

Are you CURRENTLY under treatment for any medical condition?

SOCIAL QUESTIONNAIRE

Have you been arrested?

Do you have a history of alcohol abuse?

About how many drinks do you usually have per week?

How often does drinking alcohol negatively affect your relationships with friends and family?

If you start drinking, how difficult do you find it to stop?

Do you have a history of drug use?

What types of drugs (not including drugs that were prescribed to you) are you using currently or have used in the past? Select all that apply.

Wrap Up

Which Course Dates are you interested in?