Full Legal Name
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First Name
Last Name
Phone
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(###)
###
####
Email
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Address
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Please include city, state, and zip code
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about us?
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All Ketamine Treatment services are self-pay (paid out of pocket by patient) in advance and on date of service. Have you ever received Ketamine in a clinical setting for mental health?
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Have you ever used Ketamine recreationally?
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Please describe and list all symptoms for which you’re seeking treatment (including anxiety, suicidal thoughts, feeling low, sleep issues), length of these symptoms, and if you’ve ever received treatment for them before. Insomnia, nightmares, anxiety, anhedonia
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Please list any mental health diagnosis (PTSD, Anxiety, Depression, OCD, Substance Use Disorder, Bipolar I or II, Borderline Personality Disorder, etc.) that you’ve ever been given by a mental health professional previously.
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To your knowledge, have you ever had a manic episode?
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To your knowledge, have you ever had a psychotic episode?
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Have you ever been an inpatient in a mental health facility or taken to the ER for mental health reasons in the past?
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Do you think about ending your life?
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Do you have any previous suicide attempts?
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Do you live alone?
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Are you currently using Alcohol, Cannabis, Cocaine, Psychedelics, or other mind-altering substances not listed? If so, please be specific and list substance and amount per day or week (if none, list NA):
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Please list Primary Care Provider and date last seen (if none, put NA):
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Please list Psychiatric Provider and date last seen (if none, put NA):
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Please list current medications and all supplements you are currently taking (if none, put NA):
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Please list psychiatric medications you’ve taken in the past but are no longer taking:
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Are you in therapy and if so, for how long?
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Is there anything else we did not ask that you would like to share with our team?
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Emergency Contact - Name/Phone
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