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PCIS Registration Intake Form - First Responder

Please complete this entire registration form in as much detail as possible so that we may best serve your individual needs throughout the session. Estimated time to complete:  30-60 minutes.

Click the button below to start.

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Question 1 of 37

For which PCIS session are you registering?

A

June 23-26, 2025 | PCIS: Adult Children of 1st Responders

B

August 25-28, 2025 | PCIS for First Responders

C

September 22-25, 2025 | PCIS for First Responders

D

October 20-23, 2025 | PCIS for Command Staff (Captain and above)

E

November 3-6, 2025 | PCIS for First Responders

Question 2 of 37

We request that no weapons be worn during the seminar. Please secure weapons in your vehicle or your room. An armed police officer will be on site.

A

I agree to attend the workshop without my weapon.

REGISTRATION INFO

Hi! Tell us a little about yourself.

Question 4 of 37

Participant Name
If there is also a nickname you would prefer to be called, list that here.

Question 5 of 37

Please list your department or agency, as well as the city and state.

Question 6 of 37

Years of service as a First Responder:

Question 7 of 37

Please select your area of First Responder experience.

(Select all that apply)
A

Law Enforcement

B

Corrections

C

Fire Service

D

EMS / Paramedic

E

911 / Communications

F

Medical Examiner

G

Spouse

H

Fiance'

I

Significant Other

J

Partner

Question 8 of 37

Your Gender

A

Male

B

Female

C

Other

Question 9 of 37

Race / Ethnicity

CONTACT INFORMATION

We will need to contact you - 

> with more information about your PCIS session;

> with any questions we have;

> to confirm we are best prepared to support you.

Please provide accurate contact information and be sure to respond.  We are here to help you and can do that best with 2-way communication.

Question 11 of 37

We will need to contact you between now and the PCIS session. Please provide information here that will help us do that efficiently.
Work Phone #: 
Work Cell #: 
Personal Cell #: 
Home Phone #: 
At which # would you like to receive phone calls?
At which # would you like to receive text messages?

Question 12 of 37

We will send you more information on the PCIS session via email.

Please provide your personal email address here.

Be sure to check your email frequently for updates and information on your PCIS attendance.

Question 13 of 37

Your preferred method(s) of communication:

(Select all that apply)
A

Phone call

B

Text message

C

Email

D

Printed & mailed

Question 14 of 37

How would you like your name to appear on your name tag?

Question 15 of 37

If there is a preferred weekday or time of day to reach you, please list that here.

PERSONAL INFORMATION

Note: If someone will be attending with you, they are required to complete and submit their own, separate registration.

Question 17 of 37

Will someone be attending the PCIS with you?

A

Yes

B

No

Question 18 of 37

If someone will be attending with you, please list their:
Name
Phone #
Email address
We will follow up to provide them with the registration form.

Question 19 of 37

Relationship Status

(Select all that apply)
A

Married

B

Separated / Divorcing

C

Engaged

D

In a relationship / Significant other

E

Single

HEALTH AND EMERGENCY INFORMATION

Please provide any information we may need during your time at PCIS.

Question 21 of 37

Please list any health and/or mobility concerns:

Question 22 of 37

Please list any food allergies:

Question 23 of 37

Please list any other allergies of concern:
(Medications)
(Other: Plants (poison oak/ivy), animals (dog/cat/etc.), etc.)

Question 24 of 37

Do you carry an epi-pen or other medical emergency device or medication that we should be aware of? Please explain:

Question 25 of 37

Who is your emergency contact?
What is their cell phone #?

INCIDENT AND/OR TRAUMA INFORMATION

This information will be protected and kept confidential, for use only with the PCIS to help us best support you in your journey. We appreciate your trust in us.

Question 27 of 37

Please describe the critical incident or the type of multiple traumatic incident(s) in which you have been involved.

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.

Question 28 of 37

Are you aware of any reactions or changes in yourself since your incident(s) or trauma? (Yes / No)
What are the reactions or changes in yourself after your incident(s) which bring you to our seminar?

(i.e. increased anger; sleep difficulties; relationship problems, flashbacks; increased work difficulties; etc.):

Question 29 of 37

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.

Question 30 of 37

Are you experiencing any changes or reactions which have caused increased use of alcohol or other substances since your incident(s)?

A

Yes

B

No

ALL PARTICIPANTS PLEASE NOTE:

Alcohol/substance abuse

is not allowed at the PCIS.

If you have ANY concerns

please let us know ahead of time.

Question 32 of 37

What is the outcome that you would like to achieve post seminar?

Question 33 of 37

Have you served (past or present) in the military?

A

Yes

B

No

Question 34 of 37

Are you currently engaged in therapy or counseling with a Mental Health Professional (MHP)?

A

Yes

B

No

Question 35 of 37

If "yes," do we have your permission to contact them to help facilitate our best efforts to assist and support you?

A

Yes

B

No

Question 36 of 37

If "yes," please provide their name and best contact phone number here.

DO YOU HAVE QUESTIONS?

If you have any questions, please contact:

Jill Newman - [email protected]
405-285-0544

or

Mark Calhoon - [email protected]
405-285-0544

Confirm and Submit