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PROGRAM VALKYRIE

Start Your Intake

Apply for a psychedelic therapy session to embark on a journey of healing and recovery.

    Do you identify as (check all that apply)
    LGBTQIA+BIPOCMilitary Sex Trauma (MST) Victim

    Are you a veteran or non-veteran?

    Are you the spouse of a veteran?

    Are you currently in a state of crisis or an emergency situation where there is immediate concern surrounding the survival of yourself or others.
    If you are in immediate/imminent danger, please dial 988 immediately and press 1 to speak with a fellow veteran.

    Please tell us your biggest stressor at this point in time

    Please provide us with further details about your current situation

    Have you experimented with psychedelics within the past two years?

    Do you have any medical conditions or mental health diagnoses?

    Do you relate to any of the following?Breast Cancer SurvivorSuffering from Chronic PainIn Active Addiction'Active addiction' meaning current use of substances with unhealthy dependency and unable to stop use.)

    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?

    Which of the following treatments and/or procedures have you received in the past?12 Step ProgramsPsychotherapyNeurofeedbackMeditationOther

    Which of the following treatments and/or procedures have you received in the past? (select all that apply)12 Step ProgramsPsychotherapyNeurofeedbackMeditationOther

    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

    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

    Why are you 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?