Ketamine Intr — LYNN KREADEN

Ketamine Interest Form

Name

First Name

Last Name

Email

Phone

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

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Medications *

Why are you interested in Ketamine Assisted Therapy?

What are your intentions and hopes around this treatment?*

Which of these are currently applicable to you?

Use of MAOI's / SSRI's / SNRI's. If you don't know what these are, then this is likely not applicable to you ;-).

Heart conditions or serious cardiovascular problems.

Auto-immune disease(s).

Family history of schizophrenia or early onset mental illness.

Seizures / epilespy malignant hypothermia or other types of susceptibility to heat stroke.

Elaboration:

Have you ever been hospitalized for a mental health Issue?

Have you ever been diagnosed with a mental health issue, or mental disorder?

Have you been or are you in psychotherapy?

Do you have a support system in place, post session?

What kind of ketamine experience are you looking for?

One-on-One

Group Ketamine Experience