Heroic Hearts Project Application

What type of Heroic Hearts Project applicant are you?

Are you a Veteran or a Non-Veteran?

Are you the spouse of a Veteran?

Updating Your Application

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

Personal Details

First Name

Last Name

Gender

Email

Phone

Birthdate

mm/dd/yyyy

Occupation

Do you identify with any of these special populations?

Note: BIPOC is an abbreviation for "Black, Indigenous, People of Color."

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

Address

Street

City

State/Province

Zip/Postal Code

Country

Your Military Service

Country of Service

Other Country

Branch of Service

Special Operations

Yes

Specify SOF Unit

Military Occupation Specialty (MOS)

Date Entered Service

mm/dd/yyyy

Date of Separation

mm/dd/yyyy

Separation Status

Number of Combat Deployments

e.g. 1.9

Upload proof of military service document (DD214 for US Veterans).
Your application CANNOT be approved without this document.

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.

Your Spouse's Military Service

Country of Service

Other Country

Special Operations

Yes

Military Occupation Specialty (MOS)

Date of Separation

mm/dd/yyyy

Separation Status

Number of Combat Deployments

e.g. 1.9

Please provide a description of your spouse's 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 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.

Current State

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.

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

Reason for Crisis

Please describe your current situation

Page 4

Psychedelic History

Have you experimented with psychedelics within the past two years?

Which of the following psychedelics have you previously experimented with?

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

5-MeO-DMT

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

Ayahuasca

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

Iboga/Ibogaine

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

Ketamine

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

LSD

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

MDMA

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

Peyote/San Pedro

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

Psilocybin

Microdose use?

Date of last microdose use

mm/dd/yyyy

Macrodose use?

Date of last macrodose use

mm/dd/yyyy

How many times used within the last two years?

In what capacity of use?

Medical History

Do you have any medical conditions or mental health diagnoses? Please describe them

Are you currently taking an SSRI?

Are you currently taking an SNRI?

Have you been diagnosed as Type I Bipolar

Have you been diagnosed as Type II Bipolar

Do you require the use of a wheelchair?

Are you currently taking any other 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

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

Please describe the result(s) of each treatment.

Do you relate to any of the following? * "Active addiction" meaning current use of substances with unhealthy dependency and unable to stop use.

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:

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

Intentions & Objectives

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

Is there anything else you would like us to know as we consider your application?

Spouse/Partner

Would you like to share your spouse or partner's information so we can provide them with access to our family support resources and coaching opportunities? "Partner" may be defined as your girlfriend or boyfriend, significant other, or caretaker.

YesNo

Spouse/Partner Type

SpousePartner

Spouse/Partner First Name

Spouse/Partner Last Name

Spouse/Partner Email

Referral Details

How did you hear about us?

Who/Which One?

Application Confirmations

Financial Contribution

Our Veteran Retreat Programs cost on average $5,000 Domestic/$6,000 International per veteran served.

The Heroic Hearts Project Grant is available to you if you cannot afford to pay your own way. We’d like for you to consider the following contribution amounts. Each participant is encouraged to pay what they can, and should consider what they can afford based on their own financial picture as well as the intended impact of the HHP program they are attending. Every contribution is paid forward to support a future veteran in need of services.

Financial contribution suggestions below listed as Domestic/International

$300/750 - This is the requested minimum contribution, and is a contribution for participants experiencing financial hardship. This is designed for those who genuinely require financial assistance. This may include members of equity-denied communities, those working in essential care professions, students, teachers, or anyone in financial distress.

$1000/1600 - This contribution covers the flights for another veteran, and is affordable for most. This tier is for those with a basic level of financial security. Please consider this amount if you have steady employment, own a car, feel comfortable eating at restaurants, etc.

$3000/3600 - This contribution covers the retreat costs and flights for another veteran participant. This tier is for those participants who have extra income or assets and feel called to contribute to the financing of others. Please consider this amount if, for example, you are comfortable with leisure travel, attend festivals, and have disposable income and/or bonus assets, e.g. "toys" like boats, jet-skis, motor-cross bikes, off-road vehicles, etc.

$5000/6000 - This contribution covers the full retreat costs, flights, and coaching for another veteran participant; the entire package. This tier is for those who consider themselves successful in business, investments, and in life. Contributions at this level do so much to help us provide access and inclusivity in this veteran mental health community.

We also accept other amounts, and even small ($5-$20) recurring monthly gifts are a great way to support HHP programs with minimum impact to the Veteran's overall financial position.

I confirm I have read and understand this statement.

Passport Requirements

Participation in any International HHP Retreat Program requires an active passport with validity through at least 9 months beyond the time of enrollment.

Please verify your passport expiration date now, and apply for a new one now if your expiration date is within this calendar year.

We will ask for your passport details during any Retreat Program Enrollment, and we will disqualify anyone with a passport without enough eligibility.

I confirm I have read and understand this statement.

Medical Advice
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.

I confirm I have read and understand this statement.

Supporting the Mission

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

Application Accuracy

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

SF Prior Application ID