343 FUND APPLICATION
This grant application is completely encrypted for your privacy, confidentiality and safety. This 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 10-14 days for review and a 343 Fund representative will be in touch. *Please note we require adequate proof of employment, to be considered for this program.*
Legal Name
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First Name
Last Name
Preferred Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Have you already applied to Ambio Life Sciences?
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Yes
No
If yes, have you done an intake call with Ambio Life Sciences?
Yes
No
Gender
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Male
Female
Date of Birth
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-
Month
-
Day
Year
Date
Type of First Responder
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Firefighter
Law Enforcement
EMT
Spouse of First Responder (must have gone through 343 program)
Widow/er of First Responder
Work Status. (Please provide some form of employment or retirement from service ie. pay stub, ID, retirement letter - NO PERSONAL PHOTOS).
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Active
Retired
Other
Date of Hire
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-
Month
-
Day
Year
Date
How many years have you been or were you a full-time paid First Responder?
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File Upload
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Browse Files
Drag and drop files here
Choose a file
PLEASE NOTE: You must have served as a full-time career First Responder. You MUST be able to provide proof with dates of service of current or previous employment as a First Responder along with a valid department photo ID & DL license.The more proof you can provide the better. A picture of yourself in uniform, a drivers license only or DD214 will not suffice.
Cancel
of
Most Recent Rank & Location
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Were you ever injured in the line of duty?
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Yes
No
If yes, please describe injuries
Did you ever serve in the military?
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Yes
No
If yes, how many years did you serve?
If yes, please list branch of service.
Air Force
Army
Coast Guard
Marine Corps
National Guard
Navy
Special Operations
Other
Current Relationship Status
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Married
Separated
Divorced
Engaged
Single
Significant Other
Widow/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. Should you choose not to provide an emergency contact, we will not be able to proceed with your application. THIS CONTACT MUST BE 21 or over.
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Yes
No
Please provide name.
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Please provide phone.
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Please provide email.
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Please tell us your relationship with this emergency contact
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Spouse
Significant Other / Partner
Sibling
Parent
In-Law
Child
Friend
Do you have children?
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Yes
No
If yes, please tell us their ages.
Are you currently undergoing any therapeutic treatment?
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Yes
No
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).
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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.
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Ayahuasca
5-MeO-DMT
Iboga/Ibogaine
Ketamine Therapy
MDMA Assisted Psycotherapy
Psilocybin
Sauna / Cold Plunge
Treatments you have tried (select all that apply)
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12-Step Programs
Psychotherapy (e.g. EMDR, talk therapy)
Brain Stimulators (Wearable such tDCS)
Neurofeedback (EEG)
Transcranial Magnetic Stimulation (TMS)
Ganglion Block
Surgical Intervention
Hormone Optimization
Medications
Supplements (e.g., vitamins, etc.)
Dietary/Nutritional Recommendations
Acupuncture
Chiropractic
Yoga
Flotation Therapy
Breathwork
Meditation
Cannabis
5-MeO-DMT
Ayahuasca
Ibogaine / Iboga
MDMA
Psilocybin
Other Psychedelics
None of the Above
For treatments you have tried, please be specific as to type of therapy, duration, and if you stopped, why did you stop.
Have you ever been diagnosed with any cardiac issues?
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Yes
No
If yes, please explain
Are you currently taking any psychoactive medications? - WE MUST HAVE FULL DISCLOSURE- Examples of psychoactive medications:
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Antidepressants: Treat depression
Antimanic agents: Treat manic episodes
Antipsychotics: Treat schizophrenia and bipolar disorder
Anxiolytics: Treat anxiety
Sedatives: Treat insomnia
Stimulants: Treat ADHD
Hypnotics: Treat insomnia
DOES NOT APPLY
If yes, please list medications and dosages and length of time.
Are you currently taking any Opioids? - WE MUST HAVE FULL DISCLOSURE
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Codeine
Kratom
Hydrocodone
Methadone
Morphine
Oxycodone
Tramadol
Does Not Apply
If yes, please list name(s) of opiate, dosages and length of time using.
Do you have any history of substance abuse?
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Yes
No
If yes, please indicate.
Alcohol
Drugs (Prescription or other)
Both
Previous psychedelic use?
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Yes
No
If yes, please list modality.
Please briefly describe your sleep patterns.
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Do you have nightmares when you sleep?
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Yes
No
Have you ever had suicidal ideations?
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Yes
No
If yes, are you currently suicidal? If yes, please call 911 or the Suicide & Crisis hotline at 988 immediately
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Yes
No
Are you currently undergoing any major life changes?
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Big Move
New Job
Divorce
Separation
Custody Dispute
Illness
Marriage
Loss of Spouse
Loss of Job
Other
Willingness to Work with an Integration Coach Pre & Post Journey.
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Yes
No
Would you prefer a female or male coach?
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Female
Male
Either
Willingness to with a Breathwork Facilitator Pre & Post Journey.
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Yes
No
Would you prefer a female or male breathwork facilitator?
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Female
Male
Either
Commitment to Changing Habits.
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Not At All Committed
Slightly Committed
Somewhat Committed
Moderately Committed
Extremely Committed
Are you committed to the following?
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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 am accepted into the 343 Fund integration program.
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 I am solely responsible for payment to the service provider for the psychedelic retreat.
I understand that I am responsible for the cost of my integration unless awarded a scholarship based on proof of financial need.
I understand that 343 Fund is 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 program, I must schedule my date 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.
Acknowledgment Statement: I understand that this form is not an inquiry for education or information about psychedelic therapy. This grant request form is intended for individuals who are ready and willing to participate in psychedelic therapy and the required integration process. If you are unsure which modality is right for you or do not yet understand the potential benefits and risks, please pause here and take time to do additional research before proceeding. By agreeing below, I affirm the following: “I am ready to begin my psychedelic journey and to fully engage in the work required for healing. I understand that the purpose of the Casey Skudin 343 Fund is to provide safe access and a container for integration support —not education. I have researched the requested modalities and am prepared to begin my healing journey today.”"
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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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