Apply – Stronghold Alliance

Service Type Sought

Military First Responder

Name (First, MI, Last)

Preferred Name

Address (Street, City, State, Zip)

Phone (Home)

Phone (Cell)

Phone (Work)

Date of Birth

Driver License (State & Number):

US Citizen

Yes No

Gender

Male Female

Military Veteran

Yes No

Branch Served

Honorably Discharged (note: attach DD 214)

Yes No

Total Years Military

First Responder

Yes No

Type

LE Fire Rescue EMS

Status

Active Retired

Total Years First Responder

Current or Most Recent Branch or Agency

During service, did you sustain a brain injury?

Yes No

Have you been diagnosed with PTSD or TBI?

Yes No

If yes, when was the diagnosis made? By whom?

Do you currently have a healthcare provider or therapist?

Yes No

If yes, provider name, phone, and email

Currently taking medications related to PTSD, TBI, or mental health?

Yes No

If yes, list medications

Have you ever received HBOT before?

Yes No

Describe past/current treatments for PTSD or TBI (dates, providers, types)

Do you possess a valid driver license?

Yes No

If approved, patients provide their own transportation to HBOT centers in Northern Virginia (Fairfax County). Can you meet this requirement?

Yes No

HBOT requires multiple sessions over several weeks. Can you commit to completing the full treatment protocol?

Yes No

Do you consent to limited sharing of medical information between Stronghold Alliance and its clinical partners for coordinating your care?

Yes No

Primary Emergency Contact

Name

Relationship

Address

Phone

Is this person aware of your application?

Yes No

Secondary Emergency Contact (optional)

Name

Relationship

Address

Phone

I certify that the answers given in this application are true and complete to the best of my knowledge. I hereby grant Stronghold Alliance, Inc. permission to contact cited government agencies that maintain records, and law enforcement agencies, to obtain information contained in their record systems for use in conducting inquiries concerning my eligibility and suitability to receive HBOT.

I understand that the information obtained will be safeguarded against unauthorized disclosure to any agency or individual not having a legitimate need to know.

I understand that any misrepresentation or falsification on this application will be grounds for disqualification from receiving treatment. I further understand that approval for treatment is not guaranteed and is subject to available funding, clinical suitability, and program capacity.

If approved, I commit to participating in good faith, including attending scheduled sessions, following clinical guidance, and communicating openly with my care team.

Applicant’s Name

Date

I agree to the terms above.