Name *

First Name

Last Name

Phone *

(###)

###

####

Are you 18 years or older? *

Yes

No

Do you have any of the following conditions? *

Check all that apply.

Uncontrolled high blood pressure

Untreated or severe heart disease

Schizophrenia or other psychotic disorders

Bipolar disorder (manic phase)

Active substance dependence

None of the above

What are you seeking support for? *

Check all that apply.

Depression

Anxiety

PTSD or trauma-related distress

Chronic pain

End-of-life anxiety

Other

Are you currently taking any medications? *

Yes (please list below)

No

Are you currently working with a therapist or mental health provider? *

Yes

No

Would you like to schedule a consultation to discuss next steps? *

Yes

No

By submitting this form, you acknowledge that this is a preliminary screening and does not guarantee eligibility for ketamine therapy. *

I acknowledge.