Apply For Help Benevolence Application Applicant InformationFirst Name* Last Name* Today's Date* MM slash DD slash YYYY Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date of Birth* MM slash DD slash YYYY Gender*SelectFemaleMalePrefer not to sayRace/Ethnicity*SelectCaucasianAfrican AmericanHispanicAsianOtherPrefer not to sayAre you a student?* Yes No Are you a veteran?* Yes No 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?* Yes No If Yes, when?* Employment InformationAre you currently employed?* Yes No Employment Status* Full Time Part Time Name of current employer* Length of employment* Position* Payment Method* Hourly Salary What is your total annual income?*Please include all sources outside of your employment like investments, child support, social security, disability, etc. What is your total household income?*Please include the income of your spouse or partner and any other household income. What health insurance do you have?* BCBS United Medicare/Medicaid None Other Other health insurance* Monthly Debt ObligationsCreditor List*Use the Plus Icon to the right to add a creditorCreditorMonthly Payment Total Monthly Debt Payment* Additional InformationPlease provide any additional information that you’d like us to take into account when reviewing your application.reCAPTCHA NAVIGATE QUICK LINKS