Start your Application

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Preferred Contact Method *

Email

Phone

Text

Are you a: *

Check all that apply

Veteran

First Responder

Disaster Relief Worker

Healthcare Worker

Civilian experiencing trauma, depression, or PTSD

Other

Have you participated in psychedelic-assisted healing or alternative wellness services before? *

Yes

No

What is your approximate annual income? *

Under $20,000

$20,000 – $40,000

$40,000 – $60,000

Over $60,000

Do you currently receive any financial assistance or disability benefits? *

Yes

No

Do you have any funds you can personally contribute toward your healing work (sliding scale, partial support, etc.)? *

Yes

No

Which services are you interested in receiving support for? *

Check all that apply

Psychedelic Healing Work (ketamine, psilocybin, etc.)

Preparation & Integration Coaching

LENS Neurofeedback

Energy Work / Somatic or Breathwork

Unsure – I’d like help deciding

Do you already have a provider you’re working with?

Yes

No

Preferred format of services: *

In-Person

Virtual

Hybrid / Flexible

By submitting this form, I confirm that all information provided is accurate to the best of my knowledge. I understand that Renewing Lives Initiative is not a crisis service and that this application is for financial support toward healing services, not emergency care. *

I agree to the terms above and consent to be contacted.

I understand that submitting this form does not guarantee funding.