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?*

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 Information

Are 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 Obligations

Creditor List*

Use the Plus Icon to the right to add a creditor

Creditor	Monthly Payment

Total Monthly Debt Payment*

Additional Information

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

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Benevolence Application

Applicant Information

Employment Information

Monthly Debt Obligations

Additional Information

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