Heroic Hearts Project Application

What type of Heroic Hearts Project applicant are you?
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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Address
Your Military Service
mm/dd/yyyy
mm/dd/yyyy
e.g. 1.9

Your 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.


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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