SWX Application Survey

Take the next step in transforming your struggle into strength and submit your application for the Struggle Well Experience today.

"*" indicates required fields

Step 1 of 4: Let's get started

All fields are required unless specified optional

Please tell us about yourself*

I confirm I am an active, retired, or separated first responder

If you selected "None of the above", then you are not eligible for the Warrior PATHH Program. There are many other organizations that may fit your needs. Please refer to the National Resource Directory. If this is an emergency, please call 911, or call the National Suicide Prevention Lifeline 1-800-273-8255 available 24hrs/day.*

First Name*

Last Name*

Email*

How did you hear about the Struggle Well Experience Program?*

Friend

Warrior PATHH Alumni

Counselor/Therapist/Mental Health Professional

Online Search

Struggle Well Alumni

Department Personnel

Gary Sinise Foundation

Event

Media

Social media

Struggle Well Staff

Family

Coworker

Attended Struggle Well Training

Other

Other*

Step 2 of 4: Tell us about yourself

All fields are required unless specified optional

Contact Information

Your Street Address*

City of Residence*

State*

Zip Code of Residence*

Phone*

Demographics & living arrangement

Date of Birth*

What is your age?*

18 to 22

23 to 27

28 to 32

33 to 37

38 to 42

43 to 47

48 or older

Gender*

Male

Female

Other

How do you publicly self-identify?*

Marital Status*

Emergency Contact Name and Relationship to Them*

Emergency Contact Phone Number*

What is your current employment status?*

In regards to housing, please choose the response that best represents your personal living situation.*

You rarely have a roof over your head and you do not have any ability to choose when or where to move; It is always uncertain whether or not you will find safe shelter; you can not afford to rent or buy a place to live; you have no SAFE relatives or friends to live with.

You have little ability to choose when and where you move and could be forced to relocate somewhere less safe if your situation changes; you pay a mortgage or rent, but it is a strain on your finances; you have no SAFE relatives or friends to live with.

You have the ability to choose when and where to move and there is little chance of sudden change or relocation; you pay rent or a mortgage and your account rarely gets tight, or you live with SAFE relatives or friends.

You have complete control over when you move, but can choose only certain places to move; you pay rent or a mortgage and have some wiggle room after every payment; you could house a SAFE relative or friend if necessary.

You have total control over both when and where you move; you pay a mortgage and can easily send extra to pay down the loan, or easily pay rent; you either could have SAFE friends or relatives over to stay, or do so often with plenty of room to spare.

Please select your income range*

$0-30K

$30-60K

$60-90K

$90-120k

$120K

Step 3 of 4: Your journey

All fields are required unless specified optional

Specialty (i.e. EMS, LEO, Rescue, etc.)*

Law Enforcement Officer

Firefighter

EMS/EMT

Rescue

Corrections/Probation/Parole

Dispatcher/Comms

Emergency Management

Civilian Personnel

Date you ENTERED service as a first responder*

Date you ENDED service as a first responder (provide current date if still on active duty)*

Choose the selection which best describes your current status*

Active Duty

Retired

Voluntarily Separated

Involuntarily Separated

How long have you served or did you serve as a first responder*

0-5 years

6-10 years

11-15 years

16-20 years

21-25 years

26-30 years

30+ years

List critical incidents involved in, when, and role?*

Have you ever served in the United States Military?*

Yes

What is your current military status?

Active National Guard/Reserve

Retired

Separated

Were you injured or wounded during your service?*

Yes

If you answered "Yes" to above question, please provide a brief description of nature of injury below.*

Have you been diagnosed with a TBI (Traumatic Brain Injury)?*

Yes

Do you or others close to you think that you have emotional or psychiatric difficulties that need to be addressed?*

Yes

If you answered "Yes" to above question, please provide a brief explanation below.*

Have you sought mental health assistance from a behavioral health or medical professional?*

Yes

If you answered "Yes" to above question, please provide list of all diagnoses with approximate dates of diagnosis and any treatments received below.*

Rate you level of satisfaction or dissatisfaction with any therapies or treatments you have received. If you have not received any therapy or treatment, please select NA.*

1 - Was detrimental to overall well being

2 - Provided no change, positive or negative

3 - Provided short-term positive outcome, but results were not enduring

4 - Provided long term positive outcomes, effects still present today

N/A

Have you experienced thoughts of suicide within the past year?*

Yes

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.*

Have you ever been seen in a psychiatric crisis center or emergency room, or hospitalized for psychiatric reasons?*

Yes

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)?*

Yes

If you answered "Yes" to above, please give the name of your provider and the nature of the treatments being received currently.*

Please list the names of any current prescription medications used and what you use them for (put N/A if you have none).*

How much alcohol do you currently drink in one week?*

NA - I do not currently consume alcohol

1-3 drinks

4-7 drinks

8-11 drinks

12+ drinks

Are you currently in, or have you ever been in treatment for alcohol or substance abuse, including mutual help such as AA?*

Yes

If answered "Yes" to above, please provide brief details on circumstances surrounding treatment and approximate dates of treatment.*

In regards to drugs and alcohol, please choose the response that best represents your personal situation.*

You are completely dependent on alcohol and/or drugs; you could not be drug/alcohol free if you wanted to without hospitalization and/or a serious inpatient program; substances completely and negatively affect every area of your life.

You are severely dependent on alcohol and/or drugs; you need to attend an intensive inpatient program; substances severely and negatively affect most all areas of your life.

You are moderately dependent on alcohol and/or drugs; you can become drug/alcohol free with a sobriety program, but would benefit more from an inpatient program; substances moderately affect some areas of your life.

You utilize alcohol and/or drugs for self medication and to cope with anxiety and depression, or other issues; most of your life is not negatively affected.

You either use alcohol and/or drugs once in a while, or not at all; you have no dependency on either alcohol and/or drugs; you have either been through an inpatient care program/sobriety program or do not need to attend; no areas of your life are effected negatively.

Have you ever been convicted of a misdemeanor or felony, or do you have a pending felony charge against you?*

Yes

If you answered "Yes" to above, please provide brief details on circumstances surrounding incident and approximate dates of charge.*

Please describe any pending legal responsibility, especially if there is a required physical appearance in court (if none, then put N/A).*

Are you currently undergoing a Medical Evaluation Board or seeking disability compensation from your employer?*

Yes

Do you have a service, therapy or assistance dog?*

Yes

Please list the ways (positive and/or negative) you currently cope with or manage stress.*

Please identify specific people in your life that you rely on for support. Briefly describe how each person supports you.*

Please tell us your personal goals for attending the Struggle Well Experience program. What do you hope to achieve or change as part of your work in this program?*

Please describe why you feel that a program like Struggle Well Experience will benefit you at this point in your life.*

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.*

What support groups do you attend, or self-help activities/wellness practices do you do?*

Have you participated in any other programs (for example, with Boulder Crest Retreat, GratitudeAmerica, Camp Southern Ground, Travis Mills Foundation, Big Red Barn Retreat, Permission to Start Dreaming Foundation, etc.) in the past? Which program(s) and when?*

Step 4 of 4: Program Terms & Expectations

All fields are required unless specified optional

CONFIDENTIALITY: Respect of your right to confidentiality is of the utmost importance to creating an environment of safety and trust. Strict adherence to the confidentiality ethic is a serious matter. This means that we do not say who was here or discuss what they bring up in any aspect of this program with anyone outside of the program either now or after the program is finished. Each person here is a holder of confidentiality for everyone s/he meets here; each person's story is theirs alone to tell and to break this guideline is to breach the trust created in the Boulder Crest community. This includes posting any information about others in the program on social media websites or otherwise sharing the names or personal information of any other participants with others at any point.*

I agree to terms

I do not agree to terms

PARTICIPATION: Participants must commit to being part of all training events, group sessions and meals. Please be on time and respect yourself and others.*

I agree to terms

I do not agree to terms

No weapons are allowed on the premises, including storing them in vehicles (examples include: guns, knives of any kind, sticks, mace, etc.).*

I agree to terms

I do not agree to terms

Cell phones, laptops and tablets will be left in cabins during the day. Cabin televisions may/may not be available for your use, but please respect your cabin mates with your choice of program and volume. PlayStation, XBox and similar systems are NOT PERMITTED. Leave them at home.*

I agree to terms

I do not agree to terms

The Struggle Well Experience is a peer-based training program that relies on a variety of educational and experiential activities for the purpose of teaching life skills, increasing community integration and involvement, and promoting optimal physical, emotional, relational, financial, and spiritual health. Struggle Well Experience is not an outpatient or residential clinical treatment program and does not use licensed healthcare professionals in the delivery of programs or supervision of staff. Struggle Well Experience does not include individual, group, or family counseling or psychotherapy, pharmacological management, or medical interventions*

I agree to terms

I do not agree to terms

Proof of Service Documentation Upload:*

Drop files here or

Max. file size: 10 MB, Max. files: 5.

We deeply appreciate your commitment to our program and your service as a First Responder. To ensure that we can route your application to the appropriate Struggle Well Experience Team we kindly request that you provide documentation of your service. This could include a redacted copy of your Statement of Service or any redacted First Responder Credentials. Please upload the relevant document below and ensure any sensitive information is appropriately redacted before uploading. If you have any concerns or questions about the document upload, please feel free to reach out to us at (swx@bouldercrest.org). Your privacy and security are of utmost importance to us.

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.*

Thank you for taking the time to fill out this survey. Your honest answers help your fellow First Responders.