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AIMS Group KAP
Please fill this out to indicate your interest in AIMS Group KAP offerings. This will help us to create groups specific to the needs and interests of our patients. By filling this out you agree to be contacted to follow up on your response.
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Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Which KAP group are you interested in? Select all that apply.
*
Depression
Anxiety
Pain
End of Life
Grief
Postpartum or perinatal mental health concerns
Disordered Eating
Religious Trauma
PTSD and cPTSD
Other:
Required
If 'other', what other group theme(s) are you looking for?
Your answer
What is your experience with ketamine? Select all that apply
Never used ketamine therapeutically
Have received sublingual (SL) ketamine therapeutically (troches/lozenges/oral liquid)
Have received intramuscular (IM) ketamine therapeutically
Have received intranasal (IN) ketamine therapeutically
Have received intravenous (IV) ketamine therapeutically
Other:
If 'other,' please describe the route and/or setting below.
Your answer
Our team will be in touch with you shortly. What is your preferred phone number for scheduling?
*
Your answer
What is your preferred email address?
*
Your answer
How did you hear about the KAP program at AIMS?
Your answer
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