343 Fund Grant Request
The Casey Skudin 343 Fund is committed to helping 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. 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 5-7 days for review and a 343 Fund representative will be in touch.
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Type of First Responder
Spouse of First Responder
Widow/er of First Responder
Work Status (If selected for a grant, you will be required to provide most recent pay stub OR retirement documentation)
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Choose a file
Most Recent Rank & Location
Were you ever injured in the line of duty?
If yes, please describe injuries
Did you ever serve in the military?
If yes, please list branch of service.
Current Relationship Status
It is an important part of this journey to be as open and forthcoming as possible with your partner. Often times there are a lot of questions loved ones have. Do we have your permission to communicate with them regarding your treatment?
If yes, please provide name and phone number
Do you have children?
Are you currently undergoing any therapeutic treatment?
If yes, please describe (ie. therapist weekly)
Reason for seeking treatment at this time (Please be as forthcoming as possible).
What type of treatment are you seeking? PLEASE NOTE: We require that all applicants complete an e-course courtesy of our friends at VETS. Applicants are responsible for their own due diligence to gain knowledge about the 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.
MDMA Assisted Psycotherapy
Treatments you have tried (select all that apply)
Psychotherapy (e.g. EMDR, talk therapy)
Brain Stimulators (Wearable such tDCS)
Transcranial Magnetic Stimulation (TMS)
Supplements (e.g., vitamins, etc.)
Ibogaine / Iboga
None of the Above
Are you currently taking any psychoactive medications?
If yes, please list medications and dosages.
Do you have any history of substance abuse?
If yes, please indicate.
Drugs (Prescription or other)
Previous psychedelic use?
If yes, please list modality.
Please briefly describe your sleep patterns.
Do you have nightmares when you sleep?
Have you ever had suicidal ideations?
If yes, are you currently suicidal?
Are you currently undergoing any major life changes?
None of the above
Willingness to Work with a Coach.
Not At All Willing
Commitment to Changing Habits.
Not At All 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 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.
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 let us know who.
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