Name *

First Name

Last Name

Date of Birth *

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Phone *

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Can we send you detailed text messages? *

Yes

No

Can we leave you detailed voicemails? *

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Phone

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Phone

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Fax Number

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Phone

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Fax Number

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Phone

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What are you seeking treatment for? (Check all that apply.) *

Suicidal Ideation

Trauma

Obsessive Compulsive Disorder

Anxiety

Depression

Bipolar Depression

Addiction

Eating Disorders

Life Transitions

Other

Please check if you had or have: (Check all that apply.) *

Increased intraocular pressure

Increased intracranial pressure

Unmanaged high blood pressure

Schizophrenia or psychosis

Mania

Suicidal ideation

Pregnancy-related depression

Stroke or heart attack

Seizure disorder

Ketamine abuse or dependence

Interstitial cystitis or bladder infections

None

Do you have any previous psychedelic experiences?

Yes

No

Are you currently living in a stable and supportive environment to engage in ketamine therapy?

Yes

No