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.
Name
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First Name
Last 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.
Gender
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Male
Female
Type of First Responder
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Firefighter
Law Enforcement
EMT
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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Active
Retired
File Upload
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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, please list branch of service.
Air Force
Army
Marine Corps
Navy
Special Operations
Special Forces
Current Relationship Status
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Married
Separated
Divorced
Single
Significant Other
Widow/er
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?
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Yes
No
If yes, please provide name and phone number
Do you have children?
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Yes
No
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 be as forthcoming as possible).
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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.
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Ayahuasca
5-MeO-DMT
Iboga/Ibogaine
Ketamine Therapy
MDMA Assisted Psycotherapy
Psilocybin
Not Sure
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
Are you currently taking any psychoactive medications?
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Yes
No
If yes, please list medications and dosages.
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?
Yes
No
Are you currently undergoing any major life changes?
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Big Move
New Job
Divorce
Separation
Custody Dispute
Illness
Marriage
Other
None of the above
Willingness to Work with a Coach.
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Not At All Willing
Slightly Willing
Somewhat Willing
Moderately Willing
Extremely Willing
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 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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