First Name

Last Name

Phone *

Email *

Date of birth

What state do you currently live in?

Are you a U.S. military veteran? -

Branch of Service -

Years / Dates of Service

Have you been diagnosed with or are you seeking support for any of the following? — multiple choice

Have you previously received treatment for these concerns?

Briefly tell us what treatments or programs you have already tried.

Are you currently taking prescription medications? -

Do you have any known serious heart condition, arrhythmia, pacemaker, or uncontrolled high blood pressure?

Do you have a history of seizures or epilepsy?

Are you currently experiencing a medical or psychiatric emergency requiring immediate care like seizures or epilepsy?

What is the best time to reach you?

How did you hear about Valor To Wellness?

I understand that submitting this form does not guarantee admission into treatment and that additional medical screening may be required. I consent to being contacted by Valor To Wellness regarding my application.