HHP Domestic Program: Enrollment Request Form

HHP Domestic Program: Enrollment Request Form

Personal Details

First Name

Last Name

Birthdate

mm/dd/yyyy

Gender

Email

Phone ex. 123-456-1234

Occupation

Do you identify with any of these special populations?

Note: Non-Veteran Special Population option is intended for select donors, ambassadors, or special guests. 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.

Spouse's Separation Date

mm/dd/yyyy

Upload a picture of proof of state residence. Example: utility bill, registered mail, or drivers license.

Address

Street

City

State/Province

Zip/Postal Code

Country

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.

Reason for crisis

Please describe your current situation

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.

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?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

Ayahuasca

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

Iboga/Ibogaine

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

Ketamine

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

LSD

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

MDMA

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

Peyote/San Pedro

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

Psilocybin

Microdose use?

How many times used within the last two years?

In what capacity of use?

Date of last use

mm/dd/yyyy

Medical History

Do you have any medical conditions? 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?

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?

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

Life Circumstances

Please share any additional life circumstances or struggles since your last application, if you have applied previously.

Emergency Contact

First Name

Last Name

Relationship

Phone ex. 123-456-1234

Email

Note: Your responses to the questions below will not preclude you from participation in our programs, but can help us understand which program best suits your needs or preferences.

Participation Preferences

Preferred coach gender

Are you willing to participate in a retreat that is part of a research study?

Are you willing to participate in a retreat that is part of a filmed documentary?

Which of the following options best describes your preference for HHP using your name, image, and/or testimonial quotes?

Participation Limitations

Do you have any mobility concerns that may prevent you from climbing steep stairs or elevations?

Do you require the use of a wheelchair?

Do you require the use of a medical assistance device that uses electricity (ex: CPAP sleeping machine)

If yes, please confer with your prescribing physician to determine if you can safely go without for up to 10 days. Be prepared to report your findings on your intake call with HHP.

Do you have any food allergies or restrictions?

What are your food allergies or restrictions?

Application Confirmations

Financial Contribution

Our Veteran Domestic Retreat Programs cost on average $5,000 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.

$300 - This is the requested minimum financial 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.

$1,000 - This financial contribution covers the costs of meals, transportation and accommodation 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.

$3,000 - This contribution covers the costs of the retreat 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 concerts, and have disposable income and/or bonus assets, e.g. "toys" like boats, jet-skis, motor-cross bikes, off-road vehicles, etc.

$5,000 - This contribution covers the full program costs per participant that includes enrollment, administration as well as group and individual 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.

I can contribute $2,500 (half of the cost of one retreat) before the end of my HHP Program.

I can contribute $5,000 (the full cost of one retreat) before the end of my HHP Program.

I can cover the cost and provide my own transportation to the retreat location.

Readiness to Enroll & Participate

I agree to participate in a video intake call with a HHP Team Member to discuss my mental and physical readiness to participate in a HHP Retreat Program.

I agree to participate in a Medical Screening phone call with a HHP Team Member who will assess my mental and physical readiness to participate in a HHP Retreat Program.

I understand that before 3 weeks of the retreat start date, I will need to stop or reduce most medications and all recreational drug/substance use. These will be identified during the medical screening, however the process to reduce or stop medications needs to be coordinated with my prescribing physician.

Mentally, I understand that I must feel called to use psychedelics as a tool for healing versus pressured to participate from someone else.

- Know your why. Setting intentions is the key to understanding any profound experience.

- Mental and emotional work is hard. From preparation through integration, it is a must.

- I’m solely responsible for my own growth, and understand the HHP Team or Retreat Staff will act as guides.

- I’ve done my own research, and feel this is a good fit for me at this time in my life.

- I understand that while at the retreat location, I will have no communication with the outside world (aside from emergencies).

I’m confident that I am able to leave my home and/or work commitments for the duration of the retreat, including travel days.

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.