Patient Assistance Fund Application - Firefighters

Patient Assistance Fund
Firefighters

The Change Your Brain Foundation is proud to support the firefighters of Los Angeles and Orange County who have been on the front lines battling the devastating LA fires. Through our scholarship program, we are offering 100 full evaluations, providing comprehensive assessments, brain scans, diagnoses, personalized treatment plans, therapy, hyperbaric oxygen therapy (HBOT), follow-up visits, and additional supportive services. Our mission is to help those struggling with trauma, PTSD, anxiety, depression, and other mental health challenges by offering cutting-edge care designed to promote healing and resilience. We are committed to giving back to those who have risked their lives to protect our communities.

Please fill out the application below to apply.

First Name

Last Name

Phone

Mailing Address

Date of Birth

Referred by (specify name and relationship):

Are you applying for yourself?
YesNo

(If not, please state your name and relationship to the applicant):

Why are you seeking care at Amen Clinics?

How have these concerns impacted your daily life?

Have you been diagnosed with any psychiatric or neurological disorders?

What types of help/interventions have you already sought and what were the outcomes?

Rate your current percentage of normal functioning, 100% being expected normal, for the following areas (scale 0-100%):

Cognitive:

Physical:

Emotional:

What are your primary goals and expectations for treatment?

Why do you need financial assistance to access Amen Clinics’ services?

Is there anything else we should know about you?

What specific help are you asking the Foundation to provide?

Eligibility Verification: This exclusive offer is available to firefighters and first responders who were impacted by the California fires in January 2025. To qualify, please upload a clear image of your official ID card as proof of your status. Only valid firefighter or first responder IDs will be accepted. Thank you for your service!

Do you Consent to Providing a Video Testimonial
YesNo

Do you Consent to receive Follow Up Feedback via Text, Phone Calls, and Email
YesNo

Patient Assistance Fund Firefighters

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Patient Assistance Fund
Firefighters