2026 Course Intake - 2ID ROK

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* 1. Your Information

Last Name

First Name and Middle Initial

Rank (Add (P) if Promotable) or CIV

YOUR NAME as you wish it to appear on the Graduation Certificate

Branch of Service

Years of Service

Platoon

Company

Battalion

Brigade

Official e-mail address

Personal e-mail address

Work Phone

Cell Phone

Current Address:
Street

City, State

Zip Code

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* 2. Assigned Course Session

Morning 0730-1200

Afternoon 1200-1630

Unsure

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* 3. Gender

Male

Female

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* 4. Date of Birth

MM/DD/YYYY

Date

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* 5. Number of Deployments (Push 'OK' when done)

10 (Or More)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. Number of Blasts (Push 'OK' when done)

10 (Or More)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Did you ever lose consciousness after a blast?

Yes

N/A

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* 8. Number of Personnel You Personally Supervise

Military Personnel

Civilian Personnel

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* 9. Marital Status

Single

Married

Separated

Divorced

Widowed

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* 10. If currently Married, were you previously divorced

Yes

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* 11. If Married - Spouse Information:

Name (First, MI, Last) - Include Rank if applicable

Spouse e-mail

Spouse Phone Number

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* 12. If Married, are you Dual Military?

Yes

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* 13. If Married, will your Spouse attend the course?

Yes

Unsure

YOUR SPOUSE'S NAME as your spouse wishes it to appear on the Graduation Certificate (If Applicable):

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* 14. Number of Children

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* 15. Are you a Single Parent?

Yes

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* 16. Chain of Command

1SGT or Supervisor Name

1SGT or Supervisor Phone

1SGT or Supervisor e-mail

Commander Name

Commander Phone

Commander e-mail

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* 17. Do you have a TS Security Clearance or are you in a Special Duty Program:

	Yes	No
TS Security Clearance	TS Security Clearance Yes	TS Security Clearance No
Personnel Reliability Program (PRP)	Personnel Reliability Program (PRP) Yes	Personnel Reliability Program (PRP) No
Presidential Support Program (PSP)	Presidential Support Program (PSP) Yes	Presidential Support Program (PSP) No
Sensitive Duty Program	Sensitive Duty Program Yes	Sensitive Duty Program No

You will have an opportunity to see a Physical Therapist, Psychologist, Financial Counselor, Spiritual Counselor, and Hypnotherapist in a One-to-One Session during the Course. Your answers to the questions below will help us better prepare for the sessions and understand your concerns and goals.

THIS INFORMATION IS ONLY FOR USE DURING THE COURSE AND WILL NOT BE SHARED WITH ANYONE OR RECORDED IN YOUR MEDICAL RECORDS.

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* 18. One-on-One Sessions - Check Specialties you would like to see for a One-on-One Session (Note: You must have at least one One-on-One Session to graduate)

Psychologist

Physical Therapist

Financial Counselor

Spiritual Counselor

Hypnotherapist (Hypnosis or Guided Imagery / Deep Relaxation)

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* 19. Do you have any schedule conflicts during this course? If so, please let us know the date(s) and time(s) of the schedule conflicts.

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* 20. How many hours of sleep do you get per night on average?

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* 21. Rate Your Sleep (Push 'OK' when done)

0 (Poor Sleep)

10 (Great Sleep)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 22. Rate Your Stress Level (Push 'OK' when done)

0 (No Stress)

10 (Very High Stress)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 23. What are the Top Three Stressors in your life?

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* 24. Do you have any pain that limits your physical training or activities?

Yes

If YES, please describe the pain and any physical limitations. When did the symptoms start? What caused the symptoms? What makes the symptoms better? What makes the symptoms worse?

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* 25. If Yes, Indicate where you have pain, what side you have pain, and the intensity of the pain (Leave blank if there is no pain).
0 = no pain 10 = intense pain

Neck

Shoulder

Elbow

Forearm

Wrist / Hand

Upper Back

Lower Back

Hip

Knee

Ankle / Foot

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* 26. PT Individual Session Questions.
When you see the 360° Physical Therapist would you like to discuss (check all that apply):'

Injuries

Pain

Weight loss or maintenance goals

Achieving height and weight standards

Fitness Programming

ACFT

Strength Training

Running

Working out around injuries

Physical Therapy as a career

Other (please specify)

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* 27. RANK Your PT Priorities

Pain / Injury

Nutrition

Fitness Programming

Healthcare - PT as a profession

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* 28. Physical Performance
Do you have any performance issues or concerns? What are your performance goals?

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* 29. Recurrent Injuries
Do you have a history of recurrent injuries?

Yes

If Yes, Briefly describe your injury:

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* 30. Trauma
Have you experienced significant trauma (as a child or as an adult)?

Yes

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* 31. Were you ever a victim of assault or abuse?

Yes

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* 32. Rate Your Childhood

0 - Very Poor

5 - Neutral

10 - Very Good

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 33. Health and Fitness Goals
Check the 3 most important areas you would like to focus on during the course:

Improving my sleep

Not reacting so emotionally

Adjusting to recent change

Reducing my sensitivity to criticism

Improving communication skills

Feeling less guilt

Better managing my health

Allowing myself to express feelings more

Better accepting loss / death

Strengthening my spirituality

Achieving financial independence or stability

Feeling less anxious / fearful

Improving marital / family relationships

Better managing my temper

Feeling more self-confident

Improving time management skills

Discussing thoughts of harming self

Having more fun

Controlling my use of alcohol

Learning how to improve relationships with others

Adapting a healthier nutritional lifestyle

Better managing my pain

Learning how to relax

Thinking more positively

Feeling less depressed

Worrying less

Better tolerating my mistakes

Not taking disappointments so hard

Discussing thoughts of harming others

Adjusting better to a past incident

Improving physical strength and flexibility

FINANCIAL STATUS QUESTIONS. Your answers to the questions below will give the Financial Counselor an idea of the financial topics to address during your session. THIS FINANCIAL INFORMATION IS ONLY FOR USE IN THE FINANCIAL COUNSELING SESSIONS AND WILL NOT BE SHARED WITH ANYONE.

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* 34. If Married, will your Spouse join you in the Financial Counselor Session?
We Highly Recommend It

Yes

Possibly

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* 35. Financial Questions

When was the last time you checked your credit report?

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* 36. How many auto loans / leases do you have?

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* 37. What Retirement Plan do you fall under?

Traditional

BRS

FERS

Other (please specify)

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* 38. Financial Goals

Short Term Goals (< 3 years)

Mid-Term Goals (3-10 years)

Long Term Goals (10+ years)

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* 39. If Married, do you feel that you and your Spouse have the same financial goals and vision?

Yes

Please explain.

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* 40. What do you like best about how you manage your finances?

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* 41. What would you like to improve or change about how you manage your finances?

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* 42. Do you have a family member, friend, famous personality who you look to for reliable financial advice?

Yes

If Yes, Please explain.

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* 43. Have you ever received financial advice from a professional either on or off your military installation?

Yes

If Yes, please explain.

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* 44. When you are interested in learning more about something, what do you do? What is your learning style (for example, do you read a book, consult a trusted resource to discuss, listen to a podcast, other ---)?

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* 45. Do you have any major financial concerns you would like to discuss?

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* 46. TOP QUESTIONS. We will be covering many topics in this course and want to make sure we are answering your questions. Here is a list of the Topics we cover. Please add any questions you might have in the text boxes. You can add more than one question for a topic - or you can skip a topic if you don't have any questions. Thank you!

Stress and Stress Management

Sleep

Time Management

Nutrition

Physical Fitness

Pain Management

Substance Abuse

Psychological Fitness

Anxiety and Depression

Brain Health

Debt Management

Financial Fitness

Couples Communication

Sex and Relationships

Parent-Child Communication

Domestic Violence

Spiritual Fitness

Managing Change

Resiliency

Leadership

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* 47. Additional Comments

Thanks. Be sure to click on the "CLICK HERE TO SUBMIT" Button below - otherwise, your survey will not be recorded.

WELCOME TO 360°!

WE ARE LOOKING FORWARD TO A GREAT COURSE!

	Yes	No	N/A
Do you have children?	Do you have children? Yes	Do you have children? No	Do you have children? N/A
Do you have an Emergency Fund?	Do you have an Emergency Fund? Yes	Do you have an Emergency Fund? No	Do you have an Emergency Fund? N/A
Do you have a budget?	Do you have a budget? Yes	Do you have a budget? No	Do you have a budget? N/A
If so, do you utilize it?	If so, do you utilize it? Yes	If so, do you utilize it? No	If so, do you utilize it? N/A
Do you spend less than you earn?	Do you spend less than you earn? Yes	Do you spend less than you earn? No	Do you spend less than you earn? N/A
Do you have a mortgage?	Do you have a mortgage? Yes	Do you have a mortgage? No	Do you have a mortgage? N/A
If so, is your mortgage Federally backed?	If so, is your mortgage Federally backed? Yes	If so, is your mortgage Federally backed? No	If so, is your mortgage Federally backed? N/A
Do you have student loans?	Do you have student loans? Yes	Do you have student loans? No	Do you have student loans? N/A
If so, are your student loans private (rather than Federal student loans)?	If so, are your student loans private (rather than Federal student loans)? Yes	If so, are your student loans private (rather than Federal student loans)? No	If so, are your student loans private (rather than Federal student loans)? N/A
Are you currently making payments on your Student Loans?	Are you currently making payments on your Student Loans? Yes	Are you currently making payments on your Student Loans? No	Are you currently making payments on your Student Loans? N/A
Do you carry credit card debt?	Do you carry credit card debt? Yes	Do you carry credit card debt? No	Do you carry credit card debt? N/A
Do you have any other loans?	Do you have any other loans? Yes	Do you have any other loans? No	Do you have any other loans? N/A
Do you track your daily spending?	Do you track your daily spending? Yes	Do you track your daily spending? No	Do you track your daily spending? N/A
Do you actively cut costs (for example, by using coupons and comparison shopping)?	Do you actively cut costs (for example, by using coupons and comparison shopping)? Yes	Do you actively cut costs (for example, by using coupons and comparison shopping)? No	Do you actively cut costs (for example, by using coupons and comparison shopping)? N/A
If so, do you think you could cut costs more?	If so, do you think you could cut costs more? Yes	If so, do you think you could cut costs more? No	If so, do you think you could cut costs more? N/A
Do you save in to the TSP?	Do you save in to the TSP? Yes	Do you save in to the TSP? No	Do you save in to the TSP? N/A
Do you know how to access your TSP on-line?	Do you know how to access your TSP on-line? Yes	Do you know how to access your TSP on-line? No	Do you know how to access your TSP on-line? N/A
Do you have other savings and / or investments?	Do you have other savings and / or investments? Yes	Do you have other savings and / or investments? No	Do you have other savings and / or investments? N/A

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* 1. Your Information

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* 2. Assigned Course Session

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* 3. Gender

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* 4. Date of Birth

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* 5. Number of Deployments (Push 'OK' when done)

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* 6. Number of Blasts (Push 'OK' when done)

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* 7. Did you ever lose consciousness after a blast?

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* 8. Number of Personnel You Personally Supervise

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* 9. Marital Status

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* 10. If currently Married, were you previously divorced

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* 11. If Married - Spouse Information:

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* 12. If Married, are you Dual Military?

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* 13. If Married, will your Spouse attend the course?

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* 14. Number of Children

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* 15. Are you a Single Parent?

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* 16. Chain of Command

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* 17. Do you have a TS Security Clearance or are you in a Special Duty Program:

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* 18. One-on-One Sessions - Check Specialties you would like to see for a One-on-One Session (Note: You must have at least one One-on-One Session to graduate)

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* 19. Do you have any schedule conflicts during this course? If so, please let us know the date(s) and time(s) of the schedule conflicts.

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* 20. How many hours of sleep do you get per night on average?

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* 21. Rate Your Sleep (Push 'OK' when done)

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* 22. Rate Your Stress Level (Push 'OK' when done)

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* 23. What are the Top Three Stressors in your life?

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* 24. Do you have any pain that limits your physical training or activities?

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* 25. If Yes, Indicate where you have pain, what side you have pain, and the intensity of the pain (Leave blank if there is no pain). 0 = no pain 10 = intense pain

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* 26. PT Individual Session Questions. When you see the 360° Physical Therapist would you like to discuss (check all that apply):'

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* 27. RANK Your PT Priorities

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* 28. Physical PerformanceDo you have any performance issues or concerns? What are your performance goals?

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* 29. Recurrent InjuriesDo you have a history of recurrent injuries?

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* 30. TraumaHave you experienced significant trauma (as a child or as an adult)?

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* 31. Were you ever a victim of assault or abuse?

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* 32. Rate Your Childhood

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* 33. Health and Fitness GoalsCheck the 3 most important areas you would like to focus on during the course:

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* 34. If Married, will your Spouse join you in the Financial Counselor Session? **We Highly Recommend It**

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* 35. Financial Questions

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* 36. How many auto loans / leases do you have?

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* 37. What Retirement Plan do you fall under?

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* 38. Financial Goals

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* 39. If Married, do you feel that you and your Spouse have the same financial goals and vision?

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* 40. What do you like best about how you manage your finances?

* 25. If Yes, Indicate where you have pain, what side you have pain, and the intensity of the pain (Leave blank if there is no pain).
0 = no pain 10 = intense pain

* 26. PT Individual Session Questions.
When you see the 360° Physical Therapist would you like to discuss (check all that apply):'

* 28. Physical Performance
Do you have any performance issues or concerns? What are your performance goals?

* 29. Recurrent Injuries
Do you have a history of recurrent injuries?

* 30. Trauma
Have you experienced significant trauma (as a child or as an adult)?

* 33. Health and Fitness Goals
Check the 3 most important areas you would like to focus on during the course:

* 34. If Married, will your Spouse join you in the Financial Counselor Session?
We Highly Recommend It