Grant Application | HOW Foundation of South Florida

First Name

Last Name

Birthdate

Are you able to provide your own transportation to/from treatment?

Yes

For which condition(s) are you seeking hyperbaric oxygen therapy?

Traumatic Brain Injury (TBI)

Post-traumatic stress

Concussion

Other

Please provide any details that might be helpful.

Have you received any of the following diagnoses from a medical professional?

Traumatic brain injury (TBI)

Post-traumatic stress disorder (PTSD)

Post-concussion syndrome (PCS)

When was your most recent physical examination?

Have you undergone HBOT treatment in the past?

Yes

Are you currently taking any medications for PTS-/TBI-related symptoms?

Yes

Are you currently, or are you attempting to become, pregnant?

Yes

In which program are you interested?

What sport(s) do you play?

How long have you played?

What school do you attend?

How long have you been having symptoms?

Does your school have an Athletic Trainer or Team Physician?

Yes

Not sure

Trainer/Physician Name

Trainer/Physician Phone

Trainer/Physician Email

Do you currently have a primary care physician (PCP)?

Yes

Physician Name

Physician Phone

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Any other notes/information you'd like to share?

In which branch(es) have you served?

Air Force

Army

Coast Guard

Marine Corps

National Guard

Navy

Reserves

Space Force

Are/were you a part of the Special Operations community?

Fully qualified and served in special operations unit such as Green Beret, Navy Seal, MARSOC, Air Force Special Warfare…etc

Yes

What is your current VHA disability rating?

0% or No Rating

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Video Call Consent *
The first step of our Veteran Investment Program involves an introductory video call. It will be recorded for diagnostic and reference purposes. By checking this box, you consent to this step and acknowledge that all information gathered, including the video itself, will remain private and confidential unless you decide otherwise.

Anonymized Study Consent
One of our goals is to extend our Veteran Investment Program to as many service members suffering from PTS/TBI as possible. Data-focused results and personal testimonies from those who have completed our program help us in our effort to affect healthcare legislation, acquire funding for future participants, and continue increasing access to HBOT as a life-changing therapy. While not required, your participation in our anonymized study will benefit future veterans seeking this treatment.

How did you sustain your injury?

What kind of symptoms have you encountered, and for how long?

Please provide a summary of your situation and why you would like to be considered as a candidate for a HOW Foundation program.

What are the life changes you are hoping to see as a result of HBOT treatment?

Is there anyone you would like to authorize us to communicate with on your behalf?

Your privacy is paramount. You can always add or remove people from this list later.

Are you willing to let us document your process/time through HBOT? (This may include video and photograph, as well as written testimonials.)

With your consent, your journey may be used to help us reach out to others and normalize getting HBOT for mental and brain wellness.

Yes

Please upload an official form of photo identification (Driver's License, School ID, Passport, etc.)

Choose File

Please upload a copy of your military ID (active duty) or DD214 (veteran).

These documents are required to verify service. You may submit form NGB22 if no DD214 exists.

Choose File