Wellness Funding Application

Wellness Funding Application
Project Life Spark Inc. is committed to protecting your privacy and treating your personal information with care and confidentiality.

The information you provide, including personal, medical and mental health information and supporting documents, will be used to assess your application for potential funding assistance, understand your circumstances and coordinate services where appropriate.

Project Life Spark does not provide medical care or make final clinical suitability decisions. These decisions are made by the retreat centre’s qualified clinical team and your personal physician.

Your information will only be accessed by authorized individuals and may be shared with relevant retreat providers, healthcare professionals or service providers where necessary for the purposes described above, with your consent or other lawful authority.

We use Jotform’s HIPAA-enabled features and security controls to help protect submitted information. Application information may be stored or processed in the United States or the European Union. While we take reasonable steps to safeguard your information, no electronic system can be guaranteed completely secure.

We retain information only as reasonably necessary for application assessment, program administration, charitable accountability and applicable legal obligations.

By submitting this application, you acknowledge that you have read and understood this notice. Any additional consent required for the collection, use or disclosure of your information will be obtained separately where appropriate.
Have you read the consent and understand?
Section 1: Applicant & Service Details
Name

First NameLast Name
Gender
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate your service background.
Please briefly describe your service history (e.g. branch, units, years served, primary role)
Please provide proof of service.

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Section 2: Travel & Border Readiness
Do you have a valid passport and the ability to travel internationally for treatment?
Passport Expiration Date (Note: Must be valid for at least 6 months past intended travel date).

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are there any legal restrictions (e.g. active probation, outstanding warrants, border bans) that prevent you from international travel?
Section 3: Financial Need & Co-Pay Readiness
Current Employment / Income Status:
Gross Annual Household Income:
"Project Life Spark operates on a shared-investment model to maximize the number of individuals we can help. What dollar amount can you contribute toward your travel, and lodging?
If your household income is over $110,000 CAD but you face extraordinary financial strain (e.g., loss of spousal income, catastrophic medical expenses, high debt from PTSD recovery), please briefly explain.
Section 4: Prior Psychedelic & Grant History

We ask this to ensure equitable access to funding across the community and prevent grant duplication.
Have you previously undertaken psychedelic assisted therapy (e.g. Ketamine, MDMA, Psilocybin, Ibogaine, 5-MeO-DMT, Ayahuasca)
Was any previous treatment funded by a grant, charity, or foundation?
If Yes, list the sponsoring organization, the medicine used, and the month/year attended (N/A if 'No').
Are you currently applying for, or expecting, funding from any other charity or foundation for this treatment?
"I certify that I have not attended a third-party funded ibogaine or psychedelic retreat within the last 12 months (365 days). I certify that I am not seeking duplicate funding from another organization for this treatment. I agree to notify Project Life Spark immediately if outside funding is awarded to me after submitting this application."
Section 5: Clinical Safety & Challenges
What primary challenges are you seeking to address? (Select all that apply)
Project Life Spark recognizes that childhood trauma, contact sports (e.g., football, hockey), and non-service accidents (e.g.,motor vehicle collisions) build cumulative neurological and emotional vulnerabilities that compound operational stress. Have you experienced any significant head trauma or concussions outside of your service?
If 'Yes', please briefly describe the nature of your injuries.
Are you taking any prescribed medications? This is critical for our clinical partners to assess your safety for treatment.
If 'Yes', please list the medication names and dosages.
Medication Tapering Awareness Notice: Certain psychiatric medications, specifically SSRIs, SNRIs, and Benzodiazepines, are clinically contraindicated with ibogaine and require a physician-supervised taper. If selected, participants on these medications must finalize an approved tapering schedule with the assistance of their family medical provider at least 60 days prior to retreat departure."
Statement of Treatment Need & Conventional Care History
"Please provide a detailed statement explaining why you are seeking funding for psychedelic-assisted therapy at this time.In your response, please outline:Treatment History: What conventional treatments or therapies have you already tried (e.g., VAC/OSI clinic programs, prolonged exposure, EMDR, medications, inpatient care)? What worked, and where did standard care fail to give you relief? Current Impact: How are your current challenges impacting your daily life, family, or ability to function? Financial Context: If financial hardship is a factor, please explain briefly. (Note: Financial hardship is considered, but treatment need and readiness are our primary criteria).Provide as much detail as you are comfortable sharing. All information remains strictly confidential."
I understand that certain medications, substances, and medical conditions can be contraindicated for this type of treatment. I agree to be fully transparent about my health history with the clinical team during their medical intake process.
Section 6: Participant Commitment & Readiness Agreement
Participant Readiness & Seat Rollover Terms

Project Life Spark invests a significant amount of capital to fund retreat goups. When a candidate fails to prepare, complete medical diagnostics, or communicate, that funded seat is compromised and lost to another individual on our waitlist.

We are committed to supporting and guiding you through your preparation, and will assist you in all possible ways. However, we will not engage in administrative chasing. You must take personal ownership of your healing process.

By submitting this application, you agree to the following operational policies:
- Personal Accountability: You are personally responsible for scheduling and completing all required facility paperwork, medical testing, and coaching sessions.
- The 45-Day Standard Cutoff: All pre-retreat diagnostics (including resting 12-lead ECG, bloodwork panels) and facility clearances must be completed and submitted at least 45 days prior to your scheduled retreat date.
- The 60-Day Medication Cutoff: If you require clinical tapering from SSRIs, SNRIs, or Benzodiazepines, your medical clearance and tapering protocol must be confirmed at least 60 days prior to retreat departure.
- Automated Seat Rollover: A PLS coordinator will send routine check-ins and courtesy notices via text, Signal or email. If required medical milestones remain incomplete or communications go unanswered past the cutoff deadline, your seat will be automatically revoked and rolled over to a future cohort. Your spot will be reallocated immediately to an active candidate on our waitlist.
I have read, understood, and accept the Project Life Spark Readiness Deadlines, Financial Allocation Terms, and Seat Rollover Policy. I commit to taking personal responsibility for completing my preparation on time.
Section 7: Emergency Contact & Research Consent
Emergency Contact Name

First NameLast Name
Relationship of Emergency Contact:
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Project Life Spark is dedicated to understanding and furthering the effectiveness of treatments provided through its Wellness Funding program and to the advancement of these medicines. I, the applicant, understand and accept that I may be contacted in the future to voluntarily participate in a brief follow-up process, such as answering questionnaires or screening questions related to my wellbeing before and after treatment. I agree that this data will contribute to Project Life Spark's study on the efficacy of these therapeutic approaches. By declining to participate in any future data collection, I understand that this by no means affects my ability to participate as a Wellness Funding recipient.
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Wellness Funding Application

Section 1: Applicant & Service Details

Section 2: Travel & Border Readiness

Section 3: Financial Need & Co-Pay Readiness

Section 4: Prior Psychedelic & Grant History

Section 5: Clinical Safety & Challenges

Section 6: Participant Commitment & Readiness Agreement

Section 7: Emergency Contact & Research Consent