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

Select all that apply. Hold the Command key (Mac) or Control key (PC) to make multiple selections.
Address
Military Service
mm/dd/yyyy
mm/dd/yyyy
e.g. 1.9

Spouse's Military Service
mm/dd/yyyy
e.g. 1.9
Current State

If you're in immediate/imminent danger, please dial 988 immediately and press 1 to speak with a fellow veteran.


Psychedelic History


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5-MeO-DMT




mm/dd/yyyy
Ayahuasca




mm/dd/yyyy
Iboga/Ibogaine




mm/dd/yyyy
Ketamine




mm/dd/yyyy
LSD




mm/dd/yyyy
MDMA




mm/dd/yyyy
Peyote/San Pedro




mm/dd/yyyy
Psilocybin




mm/dd/yyyy
Medical History


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Select all that apply. Hold the Command key (Mac) or Control key (PC) to make multiple selections.
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?

Intentions & Objectives



Spouse/Partner

Referral Details
Application Confirmations