343 Fund Grant Request

343 Fund Grant Request

The Casey Skudin 343 Fund is committed to helping career First Responders come back from the darkness of depression, PTSD, trauma and substance abuse. We are so happy you are here taking the first step. Please note that this grant application form asks you to provide certain personally-identifiable health information (“PHI”) to 343 Fund. By including your PHI in the form below, you authorize 343 Fund and its individual personnel to transmit your PHI to other 343 Fund personnel in order to help evaluate your application to us for grant funding. While you may refuse to provide your PHI, omitting this information from your application will prevent the 343 Fund from determining the merit of your application and awarding you any grant funds. We are not seeking to use or disclose your PHI for marketing, and we will not receive remuneration for our use or disclosure of any PHI. The 343 Fund will keep all PHI confidential, until and unless you sign a written authorization permitting the 343 Fund and its individual personnel to disclose your PHI to any third party (including any of your family members). All requests will be kept completely confidential and strictly adhere to HIPAA privacy regulations. We ask that you answer these questions as honestly as possible - this is a NO JUDGEMENT ZONE. Once your form has been submitted, please allow 7-10 days for review and a 343 Fund representative will be in touch. *Please note you must have served as a FULL-TIME First Responder for a MINIMUM of 10 years to be considered for this grant.*
Legal Name*

First NameLast Name
Preferred Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Gender*

MaleFemale
Date of Birth *

MonthDayYear
Date
Type of First Responder*

FirefighterLaw EnforcementEMTSpouse of First ResponderWidow/er of First Responder
Work Status (If selected for a grant, you must be able to prove that you have been a career First Responder for a MINIMUM of 10 years. This could be in the form of pay stubs OR retirement documentation)*

ActiveRetiredOther
How many years have you been or were you a full-time paid First Responder? *
File Upload*

PLEASE NOTE: You must have served as a full-time career First Responder for a minimum of 10 years. You MUST be able to provide proof of current or previous employment as a First Responder along with a valid photo ID & DL license. The more proof you can provide the better. A DD214 will not suffice.
Cancelof
Most Recent Rank & Location*
Were you ever injured in the line of duty?*

YesNo
If yes, please describe injuries
Did you ever serve in the military? *

YesNo
If yes, please list branch of service.

Air ForceArmyCoast GuardMarine CorpsNational GuardNavySpecial OperationsOther
Current Relationship Status*

MarriedSeparatedDivorcedEngagedSingleSignificant OtherWidow/er
It is an important part of this journey to be as open and forthcoming as possible with a spouse, partner, loved one, family member or close friend. Often times there are a lot of questions they may have. Do we have your permission to communicate with them regarding your treatment? If not married or do not have a partner, please provide an emergency contact that we can communicate with if we are unable to get ahold of you.*

YesNo
Please provide name.*
Please provide phone.*
Please provide email.*
Please tell us your relationship with this emergency contact*

SpouseSignificant Other / PartnerSiblingParentIn-LawChildFriend
Do you have children?*

YesNo
Are you currently undergoing any therapeutic treatment?*

YesNo
If yes, please describe (ie. therapist weekly)
Reason for seeking treatment at this time. Please understand that we provide grants specifically for job related traumas. (Please be as forthcoming as possible). *
What type of treatment are you seeking? Applicants are responsible for their own due diligence to gain knowledge about the psychedelic assisted therapies. We do not tell grant recipients what treatment to pursue or which treatment facility to attend; however, all treatment centers must be vetted by 343 Fund.*

Ayahuasca5-MeO-DMTIboga/IbogaineKetamine TherapyMDMA Assisted PsycotherapyPsilocybinSauna / Cold Plunge
Treatments you have tried (select all that apply)*

12-Step ProgramsPsychotherapy (e.g. EMDR, talk therapy)Brain Stimulators (Wearable such tDCS)Neurofeedback (EEG)Transcranial Magnetic Stimulation (TMS)Ganglion BlockSurgical InterventionHormone OptimizationMedicationsSupplements (e.g., vitamins, etc.)Dietary/Nutritional RecommendationsAcupunctureChiropracticYogaFlotation TherapyBreathworkMeditationCannabis5-MeO-DMTAyahuascaIbogaine / IbogaMDMAPsilocybinOther PsychedelicsNone of the Above
Have you ever been diagnosed with any cardiac issues?*

YesNo
If yes, please explain
Are you currently taking any psychoactive medications? - WE MUST HAVE FULL DISCLOSURE- Examples of psychoactive medications:*

Antidepressants: Treat depressionAntimanic agents: Treat manic episodesAntipsychotics: Treat schizophrenia and bipolar disorderAnxiolytics: Treat anxietySedatives: Treat insomniaStimulants: Treat ADHDHypnotics: Treat insomniaDOES NOT APPLY
If yes, please list medications and dosages.
Are you currently taking any Opioids? - WE MUST HAVE FULL DISCLOSURE*

CodeineKratomHydrocodoneMethadoneMorphineOxycodoneTramadolDoes Not Apply
If yes, please list medications and dosages.
Do you have any history of substance abuse?*

YesNo
If yes, please indicate.

AlcoholDrugs (Prescription or other)Both
Previous psychedelic use?*

YesNo
If yes, please list modality.
Please briefly describe your sleep patterns. *
Do you have nightmares when you sleep?*

YesNo
Have you ever had suicidal ideations?*

YesNo
If yes, are you currently suicidal? If yes, please call 911 or the Suicide & Crisis hotline at 988 immediately*

YesNo
Are you currently undergoing any major life changes?*

Big MoveNew JobDivorceSeparationCustody DisputeIllnessMarriageLoss of SpouseLoss of JobOther
Willingness to Work with an Integration Coach Pre & Post Journey.*

YesNo
Would you prefer a female or male coach?*

FemaleMaleEither
Willingness to with a Breathwork Facilitator Pre & Post Journey.*

YesNo
Would you prefer a female or male breathwork facilitator?*

FemaleMaleEither
Commitment to Changing Habits.*

Not At All CommittedSlightly CommittedSomewhat CommittedModerately CommittedExtremely Committed
Are you committed to the following?*

I commit to attend the prep calls.I commit to work with an integration coach.I commit to attend group integration calls.I commit to learn to meditate.I understand that coaching is mandatory if I receive a healing grant from 343 Fund.I understand that returning to a toxic environment and bad habits will likely impact the success of my outcome.I understand that making major life changes is part of this process.I understand that making major life decisions (substantial purchases, ending relationships, quitting my job, etc.) is not advisable for a minimum of 90 days following my retreat experience.I understand that 343 Fund is a grant writing organization, not a service provider. We legally cannot suggest or select a treatment nor can 343 Fund convince or reassure anyone regarding chosen modality.I understand that 343 Fund receives signiﬁcantly more applications than the organization can fulﬁll. If chosen, I am committed to maximizing this process to the best of my ability. I understand that ups and downs are to be expected as a normal part of the integration process.I understand that if approved for this grant, I must schedule my date with the service provider within 30 days of approval date or my approval will be revoked.I understand that the provider or service facility might require proper documentation for travel, ie. US passport or valid drivers license. I acknowledge that I am prepared and travel ready with all required documentation necessary for my journey. If not, please reapply when you have the required documents.
I understand that this form is NOT an inquiry for education on psychedelic therapy. This grant request form is for people who are ready and willing to participate in psychedelic therapy and required integration. Please agree to the following statement: "I am ready to go on my psychedelic journey and do the work required to heal. I understand that the purpose of the 343 Fund is to provide grant access NOT education. I have researched the requested modalities and I am ready to heal today."*
Full Name
Is there anything else you would like us to know about you?
How did you hear about the 343 Fund? If referred by a previous grant recipient, please provide us with their name. *
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