Intake Form

Please fill out the intake form below. Thanks!

Primary Leader's Name*
First Last
Email*
Mobile Phone*
Co-leader's Name*
First Last
Co-leader's Email*
Co-leader's Mobile Phone*
Select Program*
- Trauma REBOOT
- REBOOT Combat Recovery
- REBOOT First Responders
Course Location City, State*
Is this a new course? (if you or someone else has led a course in the past at this location or virtually then please select No)*
Is this course Open/Closed to the public? (if it's open to the public, your course will be listed on the registration form)*
Is this course in-person -or- virtual?*
Is this course a gender specific group?*
Course Start Date*
MM slash DD slash YYYY
Course Start Time*

: Hours

Minutes

AM/PM
Course End Date*
MM slash DD slash YYYY