Gathering Your Information

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Hi there! We are so happy to see that you are interested in an immersion. The first step is for us to learn a little bit more about you. This information is to ensure that our care is thorough + we may support you in the best way possible. One of our client coordinators or Dr Cat will reach out to set up a zoom interview.

First + Last Name

Phone Number

Is this for an individual, couple, or small group?

Individual

Couple

Small Group

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Any medications presently taking?

Any supplements presently taking?

Current mental health challenges, suicide ideation, or self-harm? If so, please share.

History of mental health diagnosis? If so, please explain?

Family history of bipolar or schizophrenia?

Yes

Maybe

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What is your intention for working together in an immersion?

Option 1

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Any current medical issues, medical treatments, or recent surgeries? If so, please explain.

Do you have experience with psychedelics, ketamine, or plant medicines? If so, what does that look like?

Past known trauma: Have you personally ever struggled with or been diagnosed with a mental illness? Family history of mental health diagnosis

Yes

Unsure

Other:

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Have you been a part of Dr Cat's online programs before?

Yes

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Any other questions/ comments?

Submit

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