Warrior Healing Center Welcome Form

NOTE: This Center is not affiliated with or established by any Government Agency, nor do we share your information with the Government unless you ask us to do so. This Center is simply veterans helping veterans, and there is no higher corporation or company to which we answer. This is funded by the people of Cochise County's community who care about our veteran families.

Privacy Policy Agreement I accept the terms and conditions of the WHC Privacy Policy at https://warriorhealing.vet/policy

Yes No

If you select "No", please do not continue with this form and call 520-221-4093 to continue intake.

Today's Date

Your name

Street Address

City, State, Zip

Phone number

Email address

Date of Birth

How did you hear about us or who referred you?

Upload DD214

Add file

Please upload a file

Housing Situation

House Apartment/Rent HUD/VASH Homeless Shelter Homeless I currently have housing but I have concerns about my long-term situation

Food Situation

Hungry/No Food Don't Know Where Next Meal is Coming From Sporadic/Do what I have to Pretty Good/Have a plan, sort of.... Good for now, but.... All Good

Medical Situation

No Medical AHCCCS VA TRICARE Private Insurance Medicare

Do you currently have a VA Disability Rating?

If yes, do you mind sharing your percentage? Because we like to help veterans increase that number!

Describe your education status:

Describe any legal issues you have or help you need:

Please describe any substance abuse issues you have or need help with:

No judgment here, but we are standing by to help however we can.

Do you have any physical health issues you need help with?

Do you have any mental health issues you need help with?

ie - assistance for: camaraderie needs, PTSD support, service animal training, substance abuse, etc.

Any sprituality concerns we can help with?

When receiving care, do you have a preference on your provider's gender?

Male Female No Preference

Other Combat Campaigns:

Please share any medications you're comfortable telling us about and if you're happy with them:

Relationship Status

Emergency Point of Contact

Branch of Service

Army

Navy

Air Force

Marines

Coast Guard

Years of Service

Warrior Healing Center has my permission to coordinate support and care for me on my behalf using the information above.

Yes No

Please summarize briefly your most urgent need or what we can help with first

Short and sweet please!

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