PCIS 2024 02 Registration PCIS Registration FormWelcome to the Post Critical Incident Seminar (PCIS) provided by the Warrior’s Rest Foundation. A Post Critical Incident Seminar is a 3 ½ day confidential workshop for First Responders (Current or Retired) who have experienced significant critical incidents, and these events disrupt their lives. This Seminar is a tried and tested resource for First Responders. Warrior’s Rest has recently partnered with the Emergency Responder’s Assistance Program (ERAP) to provide more of these highly effective events for First Responders. PCIS’s are also for the Spouses & Significant Others who support our first responders at home. Participating in the PCIS together is a vital part of the growth and recovery journey for the attendees of the PCIS. Your Spouse or Significant Other can have their own experience of trauma which is called vicarious trauma. Our PCIS is a 3.5-day intensive experience to learn about and overcome the reactions to a critical incident(s) First Responders encounter in the line of duty. The information that you provide in this registration is important; therefore, please read and thoroughly complete all questions. Your information will provide our Clinical Director with the information needed to prepare for our seminar. Once your registration form is completed and received, you will be contacted to confirm that your form has been received. We reserve twenty-two seats for participants. If we exceed our limit, we will have a stand-by list. All seats are on a first received basis. We recommend that you complete and return the registration as soon as possible. If you have any questions, please contact Jill Newman or Mark Calhoon at 405-285-0544 or via email: Jill@warriorsrestfoundation.org or Mark@warriorsrestfoundation.org We are glad to have you join us for our PCIS. Please know that once your registration form is completed and received, you will be contacted to confirm that your form has been received and to confirm your attendance. You will also be provided with additional information about the PCIS as well as the location of the seminar.We recommend no weapons be worn during the seminar. Please secure your weapons in your vehicles or rooms. An armed police officer will be on sight. I agree.This form is to Register for PCIS 2024 02 on Feb 18 – 21Participant Name(Required) First Last Department / Agency:(Required)City and State(Required)Years of Service as a 1st Responder:(Required)Please select what Type of First Responder:(Required) Law Enforcement Fire Service EMS 911 / Communications Medical Examiner Spouse Fiance Significant Other Partner Contact InformationWork Cell(Required)Work Phone(Required)Personal Cell(Required)Home Phone(Required)Work Email(Required) Personal Email(Required) Preferred means of communication:(Required)Preferred Name to Use on Name Tag(Required)What are the best days & times to contact you?(Required)Personal InformationATTENTION: If someone will be attending with you, they are required to complete & submit their own, separate registration. Relationship Status(Required)MarriedEngagedSignificant OtherSingleOtherWill someone be attending the PCIS with you?(Required) Yes No If Yes, Who?(Required)Health and Emergency InformationPlease list any health and/or mobility concerns:(Required)Please list any food allergies:(Required)Please list any other allergies of concern (i.e. Poison Ivy / Poison Oak / Dogs / etc.): *(Required)Emergency Contact(Required)Mobile Phone for Emergency Contact Person:(Required)Incident and/or Trauma InformationPlease describe the critical incident or type of multiple traumatic incidents in which you were involved in.(Required)For example: shooting; serious child abuse; line of duty loss of a friend or coworker, etc.; Specific details will provide us with better information on how your critical incident(s) may have impacted you and to help us ensure we have appropriate staff available.Are you aware of any reactions or changes in yourself since your Incident(s) or Trauma?(Required)What are the reactions or changes in yourself after your incident(s) which bring you to our seminar?(Required)(i.e. increased anger; sleep difficulties; relationship problems, flashbacks; increased work difficulties; etc.): *If you are a Spouse or Significant Other, please describe how the effects of the critical incident(s) on your First Responder have impacted you and/or your family.(Required)Are you experiencing any changes or reactions which have caused increased use of Alcohol or other Substances since your incident(s)?(Required) Yes No If Yes, How Often or Frequency?"(Required)If Yes, How long or duration?(Required)If Yes, Are You Currently Sober?(Required)All participants should be aware that alcohol and substance abuse is not allowed at the PCIS.What is the outcome that you would like to achieve post seminar(Required)Military ServiceHave you served (past or present) in the Military?(Required) Yes No Branch of Service(Required)Years of Service(Required)Where were you Stationed or Deployed?(Required)Were any of your incidents related to your Military Service?(Required) Yes No If “Yes”, do you consider the military incident to be the most impactful?(Required) Yes No If yes; please provide any additional details regarding the impact on you regarding the Military Incident(s):(Required)Other Mental Health InformationAre you currently engaged in therapy or counseling with a Mental Health Professional (MHP)?(Required) Yes No If “Yes”, may we contact them to facilitate our best efforts to assist you?(Required) Yes No Release of Information (ROI)If you have answered YES to the previous 2 questions, please complete the below Release of Information (ROI) By signing this Release of Information (ROI) form, I authorize my Mental Health Professional (MHP) to disclose summary mental health information including, but not limited to, his or her diagnosis to the Warrior’s Rest Foundation. This Release of Information that I am authorizing is to assist WRF in obtaining my MHP’s assistance in determining how I may best be assisted during the Post Critical Incident Seminar (PCIS). This document will only be used by the WRF MHP’s in assisting with the needs of the participant during the PCIS program. In accordance with HIPPA regulations, this form, and any information within, will not be disclosed unless requested by the participant with a signed ROI form. I understand that I have a right to cancel or modify this authorization, in writing, at any time. I further understand that such cancellation or modification must be in writing. This ROI will expire 120 days from date of signature.PCIS Registrant(Required) First Last Name of Mental Health Professional (MHP):(Required) First Last MHP Phone #(Required)MHP Email(Required) Type your name to act as a digital signature(Required)Type the date to act as a digital signature(Required)If you have any questions, please contact Jill Newman or Mark Calhoon at 405-285-0544 or via email: Jill@warriorsrestfoundation.org or Mark@warriorsrestfoundation.org
