Wingman Application

Congratulations on taking the first step in your healing journey. We understand how scary this can be.

Please note our current wait time to review applications is 2-3 weeks.

If you are experiencing a crisis, reach out to the 988 Prevention Line.

To get started, fill out your information below:
If something doesn't apply to you, just write n/a or answer 'no'

Personal Information

Date of birth *

Gender Identity

Male
Female
Non-binary
Prefer not to say
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Intention & Objectives

What type of treatment are you pursuing? *

Ayahuasca
Iboga/Ibogaine
Ketamine Therapy
MDMA Assisted Psychotherapy
Psilocybin
5-MeO-DMT
Other
Not Yet Decided
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Have you used psychedelics in the past?

Yes

How have you used psychedelics in the past?

Recreationally
Ceremonially (US)
Ceremonially (International)
Clinically
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Medical History

Have you experienced any of the following related to your military service? (Select all that apply)

Depression

Anxiety

PTSD (Post-Traumatic Stress Disorder)

TBI / Concussion (Traumatic Brain Injury)

Military Sexual Trauma (MST)

Moral Injury

Chronic Pain

Physical Injury

Substance Use Disorder

Sleep Disorder

Adjustment Disorder

Grief and Loss

Do you suffer from any medical conditions?

Yes

Are you currently taking any drugs?

Yes

Do you drink alcohol?

Yes

Social Moderation

Do you consume tobacco any tobacco products?, cigarettes, and/or chewing tobacco??

Yes

Program Details

Do you have an active passport?

Active with more than 6 months until expiration

Active with less than 6 months until expiration

Expired

No passport

Testimonials are a powerful tool to help us reach others. Would you allow us to share your story if you are selected??

Yes

Have you ever recieved a grant from another organization before?

Yes

How will you pay for treatment if accepted?*

Full Grant
Partial Sponsorship
Private Pay
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Are you interested in taking part in our Wingman Program? This program allows sponsors to pay for themselves and a hero to go on a medicine retreat

Yes

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