Apply For Help

Applicant Information

First Name*

Last Name*

Today's Date*

Address*

Phone*

Email*

Date of Birth*

Gender*

Race/Ethnicity*

Are you a student?*

Are you a veteran?*

What, if any, mental health condition have you been diagnosed with?

Have you ever received Ketamine Infusion treatment? If so, when and with what results?

Have you received financial help from The Serenity Foundation in the past?*

If Yes, when?*

Are you currently employed?*

Employment Status*

Name of current employer*

Length of employment*

Position*

Payment Method*

Annual Income*

What health insurance do you have?*

Other health insurance*

Creditor List

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Creditor	Monthly Payment

Total Monthly Debt Payment*

Please provide any additional information that you’d like us to take into account when reviewing your application.

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