343 Fund Grant Request

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*

First NameLast 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
Type of First Responder*

FirefighterLaw EnforcementEMTSpouse of First ResponderWidow/er of First Responder
Work Status (If selected for a grant, you will be required to provide most recent pay stub OR retirement documentation)*

ActiveRetired
File Upload*

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 ForceArmyMarine CorpsNavySpecial OperationsSpecial Forces
Current Relationship Status*

MarriedSeparatedDivorcedSingleSignificant OtherWidow/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?*

YesNo
If yes, please provide name and phone number
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 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.*

Ayahuasca5-MeO-DMTIboga/IbogaineKetamine TherapyMDMA Assisted PsycotherapyPsilocybinNot Sure
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
Are you currently taking any psychoactive medications?*

YesNo
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?

YesNo
Are you currently undergoing any major life changes?*

Big MoveNew JobDivorceSeparationCustody DisputeIllnessMarriageOtherNone of the above
Willingness to Work with a Coach.*

Not At All WillingSlightly WillingSomewhat WillingModerately WillingExtremely Willing
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 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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