Heroic Hearts Project Application

Please update your application by reviewing your previous responses and editing or adding any new information.

Personal Details
mm/dd/yyyy

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mm/dd/yyyy
Address
Military Service
mm/dd/yyyy
mm/dd/yyyy
e.g. 1.9

Psychedelic History





mm/dd/yyyy
Medical History


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Quality of Life Assessment

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

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?

Current State



Intentions & Objectives



Spouse/Partner

Referral Details
Application Confirmations