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Program Application

Healing Wave Aquatics is accepting applications for enrollment from military personnel, veterans, and first responders experiencing symptoms of post-traumatic stress, as well as their caregivers. Please complete this online application for review and a Healing Wave Aquatics representative will follow up with you.

Program Application

Legal Name*
First Last
Preferred First Name
Email*
Phone*
Birth Date*
MM slash DD slash YYYY
Age*
Home Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different than home address)
Street Address Address Line 2 City State ZIP Code
Gender/Gender Identity*
How do you identify?
Pronouns*
If Other Gender/Pronouns, Please List:
Demographic Information: Why do we require this information? Wave Academy is a 501c3 nonprofit whose mission is made possible through the funding of our generous donors and grantors. Grants have various reporting requirements such as demographic and financial information about the populations served, however, we will never share any information that could be used to personally identify you.
U.S. Citizen*
- Yes
- No
Are you homeless or in a transitional living program?*
- Yes
- No
Are you currently employed?*
- Yes
- No
- Retired
Are you currently enrolled in school?*
- Yes
- No
Highest level of education completed?*
Race*
Check all that apply.
- White
- Black/African-American
- Asian
- American Indian/Alaskan Native
- Native Hawaiian/Other Pacific Islander
- Other- please list below
If Other Race, Please List:
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
Marital Status*
Do you have children?
- Yes
- No
Please list the children's ages, if applicable
Complete the areas that ONLY apply to you. No information you provide will be used in a discriminatory manner.
Service Status
- Veteran
- Active Duty
- Reserve
- First Responder
- NA (Caregiver)
Number of Years in Service
Are You A Caregiver for Someone with PTSD?
- Yes
- No
Caregiver For:
Military Era Served
- World War II
- Korean Era
- Vietnam Era
- Lebanon, Grenada, or Panama
- Gulf Era (pre 9/11)
- GWOT - post 9/11 (OIF, OEF, OND)
Military conflict(s) Served
Branch of Service
Traumatic Brain Injury*
- Yes
- No
- Unsure/pending
- Decline to answer
Military Sexual Trauma*
- Yes
- No
- Decline to answer
Medical History: Please check all conditions listed below that apply to you (past or present):*
- Cancer
- Catheters/ostomies/ports
- Chlorine sensitivity
- Compromised immune system
- Current open wounds/rashes/skin condition(s)
- Currently infectious condition(s)
- Deep vein thrombosis/blood clots
- Diabetes
- Difficulty with bowel/bladder control
- Ear problem(s)
- Epilepsy/seizures
- Headaches/migraines
- Heart/circulatory condition(s)
- Heat sensitivity
- High blood pressure
- Implanted medical devices
- Low blood pressure
- Neurological condition(s)
- Osteoporosis
- Respiratory/lung condition(s)
- Not listed: I have a medical condition that is not on this list.
- None: I do not have any of the medical conditions listed here.
Do you have a history of suicide attempts or suicidal ideation?*
- Yes
- No
How did you hear about Healing Wave Aquatics?*
If Other Referral Source, Please List Here
Low Income Verification:
Healing Wave Aquatics provides access to warm water therapy to any active duty military, veteran or caregiver. We offer our program to clients from all income levels. For prospective clients whose income is below the average median income, our program is offered for free or at a very low cost. You will be required to show evidence by presenting your income documentation. All clients whose income is above the average median income will have a co-payment based on their income level.
Total Annual Household Income (include all sources of income such as employment, unemployment, retirement, disability, etc.)*
Number of people in your household*
Conditional*
- I acknowledge that I have reviewed the application instructions for Healing Wave Aquatics. I understand that all offers of services are conditional.
True*
- I certify that all information submitted in this application process is factually true, and honestly presented. I understand that I may be subject to immediate termination of services should the information I have certified be false.
Information Confidentiality*
- I understand that all information submitted in this application will not be returned to me or used for any other purpose or shared with any other agency. I further understand that all of my information will be kept confidential with my client file at Healing Wave Aquatics and I may request a copy at any time.
Signature*
Date*
MM slash DD slash YYYY
It is the policy of Healing Wave Aquatics not to discriminate in its selection process because of an individual's race, color, religion, sex, national origin, height, weight, marital status, political belief, genetic information, sexual orientation, disability or handicap which does not impair an individual's ability to perform aquatic bodywork. Healing Wave Aquatics affords all the rights, privileges, opportunities and activities available to clients.
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Success Stories

Justin Lee

Navy Veteran

Justin came home from deployment and his family realized something was different. His PTSD manifested powerfully and after an ultimatum from his future wife, he decided to reach out for help. Healing Wave Aquatics was the first treatment that allowed him to Read More

Branden Gray

Marine Corps Veteran

Branden went from Marine to firefighter but the transition was difficult and he left his PTSD unaddressed. Healing Wave Aquatics program gave Branden a "night and day" difference in his day-to-day interactions with others. Read More

Cherrie Phillips

Navy Veteran

Cherrie was having difficulty in her personal life and she was suffering from suicidal ideations. Cherrie explains how Healing Wave Aquatics helped her sleep better, increase her "emotional connectedness," and become calmer overall. Read More

James Moreno

Marine Corps veteran

James had resentment, guilt, and anger toward others. The former runner stepped on an IED. He tried to cope with his amputated leg, but until it wasn't until his warm water therapy that he could let go of the wounds of war. Read More

SUPPORT FOR VETERANS & THEIR FAMILIES

San Diego has the highest rate of veterans with PTS in the nation, which can lead to addiction, depression and even suicide.
Thousands of families struggle to cope. If you, or are someone you know, needs immediate help we recommend these contacts:
The National Suicide Prevention Lifeline (Lifeline) at 1-800-273-TALK (8255), or text the Crisis Text Line (text HELLO to 741741). The deaf and hard of hearing can contact the Lifeline via TTY at 1-800-799-4889.
The Veterans Crisis Line is 1-800-273-8255 and Press 1 to talk to someone. Or, send a text message to 838255 to connect with a VA responder. You can also start a confidential online chat session at veteranscrisisline.net/get-help/chat.

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