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Boot Campaign's Health & Wellness Program screening form is designed to help determine if you are a good fit for our program. Please complete the following information to the best of your ability.
 
*THIS IS NOT A FINANCIAL ASSISTANCE/FINANCIAL RELIEF OR CRISIS-CENTERED PROGRAM*
COVID-19 UPDATE
Due to travel challenges, as well as federal and state guidelines, Boot Campaign’s Health & Wellness pipeline and the scheduling of treatment is changing daily and may not be available at the present time.
**CRISIS INFORMATION**
If you are experiencing a crisis and are contemplating suicide, immediately call the VETERANS CRISIS LINE at 1-800-273-8255 and press 1 or text 838255. You can also find more information at www.veteranscrisisline.net. If you are attempting suicide, or have committed bodily harm to yourself or others, please dial 911 immediately.  

If at the time of your application we are led to believe you are in a crisis situation we will immediately follow our crisis protocol.
MILITARY MEMBER'S PERSONAL INFORMATION













BACKGROUND INFORMATION











HEALTH AND WELLNESS INFORMATION

If you are not seeking services for one or more of these concerns, please do not submit this application.




CONFIRMATION



*Disclaimer: Boot Campaign does not discriminate on the basis of race, color, national origin, creed, 

marital status, sex, disability, age, gender identity, or sexual orientation in our organization's activities, 

including the grant process.