Heroic Hearts Project - Veteran Application
PLEASE PROVIDE DETAILED ANSWERS WHEN APPLICABLE - THIS WILL AFFECT OUR DECISION MAKING PROCESS.
Email address *
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Gender *
Occupation *
Your answer
City and State of Current Residence *
Your answer
Phone Number *
Your answer
Branch of Service *
Your answer
Please provide your MOS and a description of your military service. Please let us know about specific events that resulted in your current struggless. *
Your answer
If the whole experience costs about $3,500 how much financial assistance would you need? *
Please describe your current financial situation and would you be interested in helping us fundraise? *
Your answer
Would you be willing to be interviewed on video or do you require anonymity? Please explain *
Your answer
Do you have an active passport? *
Do you have a preference between staying in the US or traveling to another country for your ayahuasca experience? Please explain *
Your answer
Do you have any medical conditions? Please describe them *
Your answer
Do you have a personal or family history of heart condition or mental illness?
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Are you currently taking any prescription drugs? If so, please inform us of the name(s) of the drug(s) and dosage information *
Your answer
Do You have any prior experience with psychedelics? Which? *
Your answer
Tell us more about your intentions and objectives. What do you hope to gain from this treatment? Please be detailed *
Your answer
Have you tried to go through the VA to help you with these problems? Please briefly explain *
Your answer
How much time are you able to take off to dedicate to this treatment? *
Your answer
Anything else you would like us to know?
Your answer
Any questions or concerns for us?
Your answer
How did you hear about us? *
Your answer
I understand that psychedelics are not an approved therapy option within the US and that Heroic Hearts Project does not and will not offer anything that can be considered medical advice. *
Required
If I find healing through this program, I will do what I can to help other veterans and support the Heroic Hearts mission. *
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I confirm that the information given in this form is true, complete and accurate. *
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