HBOT Access Application

Healing Brainwaves has two opportunities to apply for financial support. These programs are designed to reduce financial barriers to access while honoring dignity, privacy, and fairness. This application submits you for both.
1. The Open Door Program offers a need-based price for individuals in our community who are unable to afford our already subsidized package pricing. This program offers a $100 discount per dive. If approved, your HBOT will cost $50/dive, with no limit on how many dives you may purchase.
2. The Access Grant offers 10 HBOT sessions completely covered by Healing Brainwaves. This grant is limited to the nonprofit's donation fund and is not always available.

BEFORE YOU START:

1. You must provide a brief statement (3-5 sentences or more) describing your current circumstances and why the support you are applying for would help you access care at this time.

In your statement, you may wish to include:
- Any recent changes affecting your financial or medical situation
- How this support would impact your health, recovery, or ability to function day-to-day
- Any barriers that make access to care difficult right now
2. You will need clearance from your medical team to use HBOT. Please consult your doctors before applying because you will have to confirm that you are cleared to use HBOT.

All information is reviewed confidentially and used solely to evaluate eligibility for need-based pricing through the Open Door Program.

Email address *

Name *

Date *

Occupation *

Household Annual income *

Household size: *

Number of dependents: *

Do you currently have ongoing caregiving or financial responsibility for others? *

Yes

Prefer Not to Say

Please share a brief statement (200–500 words) describing your current circumstances and why support through the Open Doors Program would help you access care at this time. You may wish to include: - Any recent changes affecting your financial or medical situation - How would this support impact your health, recovery, or ability to function day-to-day - Any barriers that make access to care difficult right now *

Financial Documentation Please upload documentation demonstrating financial need. Acceptable documentation includes (one or more): - Proof of income or benefits - Recent tax return (first page only) - Medical bills or insurance statements related to financial responsibility - Proof of unemployment or disability benefits - Medi-Cal or EBT card Important privacy line (do not skip): Applicants MUST redact any information not relevant to financial status (e.g., account numbers, diagnoses, provider notes). Do not include ID numbers, etc. *

Applicant Acknowledgments - I understand that the Open Doors Program provides limited, mission-aligned support and that assistance is not guaranteed. - I confirm that the information provided is accurate and complete to the best of my knowledge. - I understand that this program does not replace medical advice or clinical care. *

Is there anything else you would like the review committee to know?

Name *

E-Signature *