Heroic Hearts Project - Veteran Application

Page 1

Personal Details

First Name

Last Name

Birthdate

mm/dd/yyyy

Gender

Phone

How did you hear about us?

Who/Which One?

Address

Street

City

State/Province

Zip/Postal Code

Country

Military Service

Branch of Service

Special Operations

Yes

Please specify

MOS

Date Entered Service

mm/dd/yyyy

Date of Separation

mm/dd/yyyy

Separation Status

Number of Combat Deployments

e.g. 1.9

Please provide a description of your military service and let us know about specific events that resulted in your current struggles.

This is your opportunity to demonstrate your need for this program. Please give us a glimpse of your military story and then explain what you experienced (in as much detail as you are comfortable with), how it affected you then, and how it continues to affect you today. Applications with insufficient responses to this prompt will not be approved.

Background

Occupation

Do you have an active passport?

Yes	No passport

We encourage all candidates to get a valid passport as soon as possible, otherwise their ability to join our retreats will be delayed

Name as it appears on passport

Passport Number

Nationality

Date of Issuance

mm/dd/yyyy

Date of Expiration

mm/dd/yyyy

If the whole experience (retreat + travel) costs around $4,500, how much financial assistance will you need? (*This question is used for budgeting and planning purposes. Your selection for the program is not impacted by your ability to pay, but the more each veteran is able to contribute = the more veterans we are able to assist with funding.**In order to ensure each veteran is personally invested in their own healing journey, we request that you contribute a minimum of $200, if possible):

Please describe your current financial situation and would you be interested in helping us fundraise?

Testimonials and personal narratives are among the most powerful tools we can use for outreach and fundraising. If selected, would you be willing to let us share your story?

Please select your reason for seeking treatment

Tell us more about your intentions and objectives. What do you hope to gain from this treatment? Please be detailed

Please describe your support network at home. Do you have a good network of family and friends that support your healing journey? If married, how does your significant other feel about this therapy?

Heroic Hearts Project works with a partner organization, which offers programs to support partners of veterans who are undergoing psychedelic treatments. Would you like for us to refer your partner to this organization?

Yes

Partner Name

Partner Email

Is there anything else you would like us to know?

Psychedelic History

Have you ever previously experimented with psychedelics

YesNo

Which of the following psychedelics have you previously experimented with? (select all that apply)

How many times have you experimented with psychedelics?

In what capacity of use?

When was the last time you used psychedelics? (please provide date)

mm/dd/yyyy

Medical History

Do you have any medical conditions? Please describe them

Are you currently taking any prescription drugs? If so, please inform us of the name(s) of the medication(s), including their dosage and frequency.

Which of the following treatments and/or procedures have you received in the past

Please describe the result(s) of each treatment.

What is your COVID-19 vaccine status?

Date

mm/dd/yyyy

Page 2

Quality of Life Assessment

With 1 being extremely unsatisfied and 7 being completely satisfied, how would you rate your current level of satisfaction in each of the following categories:

Relationships

Employment/ Career Satisfaction

Fitness Level

Quality of Sleep

Mindset

Overall Quality of Life

Overall Health

Functional Impact

With 1 being not at all and 7 being severely, to what degree do each of the following items impact your execution of regular, daily tasks and activities?

Anxiety

Depression

Post-Traumatic Stress Symptoms

TBI/mTBI Symptoms

Alcohol Use/Abuse/Dependency

Cannabis Use/Abuse/Dependency

Opioid Use/Abuse/Dependency

Other Substance Use/Abuse/Dependency

Are you currently in a crisis state? (We define a state of crisis as as an emergency situation where there is immediate concern surrounding the survival of yourself or others.)

Reason for Crisis

Please describe your current situation

I understand that psychedelics are not an approved therapeutic option within the US and that Heroic Hearts Project cannot, does not, and will not offer any information that should be considered as medical advice

Agree

If I find healing through this program, I will do what I can to help other veterans and support the Heroic Hearts mission.

Agree

I confirm that the information given in this form is true, complete and accurate.

Agree