Patient Assistance Fund Application

Patient Assistance Fund
Application

The Change Your Brain Foundation’s mission is to end mental illness by creating a revolution in brain health. Through its support of research, educational initiatives, and patient care for those in need, we’re committed to changing the world one brain at a time and helping people lead happier, more fulfilling lives.

The Change Your Brain Foundation Patient Assistance Fund has been created to improve access to the services offered by Amen Clinics for patients who might otherwise not be able to afford them. If you have been directed to this page, someone has already identified you as a possible candidate.

The Patient Assistance Fund is ideal for the patient who is:

Interested in approaching mental and physical health concerns from a brain health perspective.
Motivated to follow the advice of an informed physician who may make recommendations including medication, nutritional supplements, nutrition, and lifestyle changes.
Lacks the resources to afford the cost of the SPECT scans and evaluation fees.

Please be aware that the process from application to clinical evaluation may take 1-2 months. The participants are selected by review of our selection committee approximately once per month. Therefore, this is not the appropriate pathway to seek help for patients who are in urgent or acute need, nor for patients who are in crisis.

If you or a loved one are in urgent need, we encourage you to go to urgent care or call one of several mental health crisis hotlines immediately. 988 is the number to call for Suicide & Crisis Lifeline across the United States and provides 24/7 service. It is available to anyone in suicidal crisis or emotional distress.

First Name

Last Name

Email:

Phone

Date of Birth

Referred by:

Are you filling out this form for yourself?
YesNo

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

Physical address of the patient:

Would you allow us to film a testimonial after treatment if the process is helpful for you?
YesNo

How did you hear about us?

What brings you to seek help with Amen Clinics?

What type of help are you looking to receive from Amen Clinics?

Please describe how the above concerns have impacted your life:

Please detail what type of help/ intervention you have already sought for these concerns:

If you have taken action, what has been the outcome so far?

Do you have any history of head injury? If so, please explain briefly:

Do you have any history of emotional trauma? If so, please explain briefly:

Have you ever received therapy or treatment for mental health or substance abuse? If so, please explain briefly, including dates:

If you have been diagnosed with any conditions, please list below:

Are you currently taking any medications or supplements? If so, please list:

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

Cognitive:

Physical:

Emotional:

Have you ever been suicidal? If yes, when?

Have you ever attempted suicide? If yes, please explain briefly, including dates:

Please state your primary goals and expectations for treatment with Amen Clinics:

Please explain why you need financial assistance to access Amen Clinics services:

Have you ever been denied treatment due to financial reasons? If so, when, and please explain:

Are you currently experiencing hardship in other areas of your life? If so, please explain:

On a scale of 1-10 (10 being very motivated), what is your motivation level to follow recommendations that may include nutrition, lifestyle, medication, and supplements?

Do you have anyone in your life who supports you emotionally, socially, or financially? If so, please explain briefly:

Please share anything else you think is important for us to know about you:

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Patient Assistance Fund
Application