Financial Assistance Application for Ketamine Treatment

Welcome to the Voyage Foundation's Financial Assistance Application Form. If you are seeking financial support for ketamine treatment, please complete the following form. All information will be kept confidential and used solely to assess your eligibility for assistance.

Financial Assistance Form:

First name

Last name

Phone

Birthday

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Company

Position

Annual Household Income

Number of Dependents

Referring Provider if Applicable

Have You Previously Received Ketamine Treatmet?

Yes

Name of Ketamine Clinic and Contact Information:

Cost of Treatment:

Amount of Assistance Required to Obtain Treatment:

Briefly describe your mental health history and current challenges:

Please provide a brief statement explaining your need for financial assistance:

I hereby give consent to the Voyage Foundation to verify the information provided in this application.

I understand that my information will be kept confidential and used solely for the purpose of assessing my eligibility for financial assistance.

Thank you for applying!  Applications are reviewed weekly.  Funds are distributed directly to the clinic upon confirmation.  If additional information is needed to verify your application a member of the team will contact you.