Eligibility/Self-Referral Form Order Number Congratulations for taking the next step forward in your recovery. Yes I’m interested in learning more about one of the following programs for Veterans and First Responders: Select Your past is not your future: Master strategies to overcome trauma Stop faking good & start feeling good: Manage your emotions and break free from harmful habits Identity & Transition: Knowing who you are beyond the uniform Community Connection Day: Finding growth together All programs are currently running with the exception of the 12 week intensive program as it is not yet funded. I’d like to have my name added to the list of potential participants. Select Yes I am interested in being put on the waitlist for the 12 week intensive program. No I understand Landing Strong Staff will contact me as soon as they have word regarding funding. For Caregivers: Yes I’m interested in learning more about one of the following programs: Select Care for the Caregiver: A program for those in supporting roles Stop faking good & start feeling good: Manage your emotions and break free from harmful habits First name * Email * Phone number * If you have already taken one of our programs, we don’t need anything more. Welcome back! If you are new to our community, we’d like to learn a bit more about you below. Last name * Allergies/dietary restrictions: Can we leave a message at this phone number? * Home address Gender Male Female Other Prefer not to say Age Who are the primary people in your support system at the moment? Mental health concerns: Have you been diagnosed with a mental health condition(s): Physical limitations/restrictions: What motivated you to contact us? What are your main goals for attending the program? Are you currently struggling with substance use issues? Would you be able to commit to being substance free during days that you are in the program? (prescription drugs permitted) Select Yes No Please note that Landing Strong offers day programming only. We do our best to respond to all enquiries in a timely manner. If you are in crisis or feel you are at active risk of self-harm, please contact your doctor or attend the Emergency Department of your local hospital.