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MEDICINE

Ketamine-Assisted Psychotherapy (KAP) Assessment Form

Please complete the survey below to register for the 20-minute Free consultation. It is important that your answers are as complete and accurate as possible in order to best facilitate next steps. Please note that all information provided will be kept strictly confidential.

First name

Last name

Email

State in which you reside

Are you pregnant or plan to get pregnant? *

Yes

No

Are you currently prescribed Ketamine or esketamine? *

Yes

No

Do any of the following conditions apply to you?

Uncontrolled high blood pressure despite treatment

Congestive heart failure or other serious heart problems

Stroke

Cerebral hemorrhage/brain bleeding

Aneurysmal vascular problem/avascular malformation

Elevated intracranial pressure

Epilepsy or seizure disorder

Allergy to ketamine

None of the above

Do any of the following statements apply to you?

I am or have been addicted to a substance other than alcohol, nicotine, or cannabis (e.g. methamphetamine, opiates)

I take any of the following medications: methadone, Suboxone, Subutex, buprenorphine/naloxone, belbuca

I have a history of bipolar disorder 1

I have active psychotic symptoms, manic symptoms, or a personal history of psychosis, schizophrenia, or schizoaffective disorder

I have active suicidal ideation with method, intent, or plan; or have attempted suicide in the past?

None of the above

Are you currently taking or have you ever taken antidepressant or anti-anxiety medication? *

Yes

No

Are you currently, or have you ever been in therapy? *

Yes

No

Do you have any questions or comments?

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