Mission Intake — Veteran Application | OOTW Veterans Restoration Initiative

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Section 01 / 06 — Personal Information

Who you are

Basic contact and personal details. This is how we reach you and verify your identity.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

State of Residence *

Preferred Contact Method *

Email Phone Call Text / SMS

Time Zone

How did you hear about OOTW Veterans? *

Section 02 / 06 — Military Service

Your service

Understanding your service background helps us tailor the protocol and support to your specific experience.

Branch of Service *

Rank at Discharge (optional)

Service Start Year *

Service End Year *

Discharge Status *

Honorable General (Under Honorable) Medical Other Currently Active

Did you deploy to a combat zone? *

Yes — one deployment Yes — multiple deployments No

Deployment theater(s) (optional)

Are you currently registered with the VA? *

Yes — actively using VA services Yes — registered, not using No

VA Disability Rating (if applicable)

Section 03 / 06 — Current Mental Health

What you're carrying

Every answer here maps directly to your protocol. The more clearly you can describe what you're carrying, the more precisely we can meet you where you are. This stays between you and us.

What are you currently dealing with? * (Select all that apply)

PTSD / Post-Traumatic Stress Depression Anxiety / Hypervigilance Chronic Pain (service-related) TBI / Traumatic Brain Injury Sleep disorders / Insomnia / Nightmares Substance use / Alcohol Moral injury / Guilt / Shame Disconnection / Loss of meaning / Identity Relationship difficulties / Isolation

How long have you been dealing with these challenges? *

How would you rate your overall mental wellbeing right now? *

1 — Severe struggle10 — Fully functional

Are you currently working with a therapist, psychiatrist, or mental health provider? *

Yes — therapist Yes — psychiatrist Yes — both No

What treatments have you previously tried? (Select all that apply)

Antidepressants (SSRIs / SNRIs) Anti-anxiety medications Individual therapy (CBT, CPT, DBT, etc.) EMDR Group therapy / Peer support VA mental health services None of the above

What are you currently taking or receiving for your mental health? *

Have you experienced suicidal thoughts in the past 12 months? *

No Passive thoughts (wishing I wasn't here) Active thoughts — no plan Active thoughts — with a plan

We see you. Please reach out now.

Veterans Crisis Line: Call 988, Press 1

Text: 838255 · Chat: veteranscrisisline.net

You can still complete this intake — but your safety comes first.

In your own words — what are you hoping to change or heal? *

Section 04 / 06 — Medical Safety Screening

Your health & safety

This section is here to protect you, not screen you out. Your complete picture is what allows us to build something that actually works for your specific situation.

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Certain conditions and medications interact with psilocybin. Your full picture here is what lets us calibrate a protocol that's safe and effective specifically for you. If you're unsure about anything, say so in the notes field.

Do you have a personal or family history of any of the following? (Select all that apply)

Schizophrenia (personal or first-degree family) Psychosis or psychotic episodes Bipolar I disorder Manic episodes None of the above

A personal history of schizophrenia, psychosis, or Bipolar I requires a direct conversation before we proceed. This doesn't automatically exclude you — it means we need your full picture first.

Do you have any of the following medical conditions? (Select all that apply)

Heart condition / Cardiovascular disease High blood pressure (uncontrolled) Epilepsy / Seizure disorder Liver disease Diabetes (Type 1 or 2) None of the above

Are you currently taking any of the following medications? (Select all that apply)

SSRIs (Prozac, Zoloft, Lexapro, Paxil, etc.) SNRIs (Effexor, Cymbalta, etc.) Lithium ⚠ MAOIs (Nardil, Parnate, etc.) ⚠ Antipsychotics (Risperdal, Seroquel, Abilify, etc.) Benzodiazepines (Xanax, Klonopin, Valium, etc.) Blood thinners / Anticoagulants None of the above

Lithium and MAOIs require a direct conversation before any protocol begins. Select them if applicable — we handle this together.

Any other medications, supplements, or substances not listed above?

Have you had any experience with psilocybin or other psychedelics before? *

No experience Limited (1–2 times) Moderate experience Significant experience

Current alcohol use *

None Occasional (1–3/week) Moderate (4–10/week) Heavy (daily)

Known allergies (food, medication, or other) *

Section 05 / 06 — Readiness & Goals

Your readiness

These questions help us build the right support structure around your actual life — not an idealized version of it. Where you are right now is exactly the right starting point.

Do you have a stable, safe housing situation right now? *

Yes — stable housing Somewhat stable No — housing is unstable

Do you have supportive people in your life (family, friends, community)? *

Strong support network Some support Mostly isolated Completely isolated

How committed are you to completing a full 90-day protocol? *

1 — Not sure yet10 — Fully committed

What is your primary goal entering this protocol? *

Reduce PTSD symptoms Reduce depression / lift mood Improve sleep / reduce nightmares Process trauma and moral injury Reconnect — with myself, family, or life Reduce chronic pain Reduce alcohol / substance dependence General healing and restoration

What does your life look like beyond the relief? *

Is there anything that could get in the way of your progress — something we should know going in?

Anything else you want us to know before your intake call?

Section 06 / 06 — Acknowledgements & Consent

Before we begin

Read through these and confirm where you stand.

Out Of This World operates as a Private Member Association (PMA) — a private trust under God and natural law, existing outside the public regulatory system through the right of free association. By completing this intake, you are entering a voluntary private membership, not a public commercial transaction.

These are God-given plants. We have taken every measure for safety, responsible stewardship, and the highest service of human healing. This program exists for the good of its members and humanity.

This is not a medical service and does not constitute medical advice, diagnosis, or treatment.

I confirm I am 18 years of age or older and a U.S. military veteran or active service member. I have answered all questions honestly to the best of my ability, including the medical safety section. I understand I am entering a Private Member Association (PMA) and accept the responsibilities of private membership under God and natural law. I understand this program is a wellness and integration support protocol, not a medical or clinical service. I consent to OOTW storing and processing the information in this form for the purpose of assessing my program application. I have read the Privacy Policy.

Reviewed personally · Response within 48 hours · alex@ootw.co