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KATALYST - Application Form
Please complete and submit this form if you would like to register for the Katalyst program.
Thank you.
It is so good to have you here with us.
Groups for 2025 -
12-week Katalyst Group - April 7, 2025 - $3800
Peri-menopause Group - April 8, 2025 - $3800
Alumni Group - Feb 13, 2025 - $2200
Training - May 7, 2025 - $2100
Wishing you well,
- Katalyst Team
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* Indicates required question
Preferred start date and program
Your answer
Name (legal or preferred)
*
Your answer
Pronouns and gender identity
*
Your answer
Date of birth (yyyy/mm/dd)
*
Your answer
Email address
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Your answer
Phone number
*
Your answer
Do you give us permission to contact you and leave a voicemail identifying who we are?
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Yes
No
Current address: (street, city, province, postal code)
*
Your answer
Racial/ethnic identity
*
Your answer
Sexual orientation
*
Your answer
Spiritual/faith tradition
*
Your answer
Emergency contact name
*
Your answer
Emergency contact number
*
Your answer
Does your emergency contact know you are participating in this program?
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Yes
No
Your support person/emergency contact is aware they need to be accessible to you for at least 24 hours after ketamine treatments in case you need/wish to access additional support.
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Yes
It is a requirement for Katalyst that you are working with a personal therapist to support you in this process.
Are you currently working with one?
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Yes
No
If no, would you like a referral to one of our recommended therapists?
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Yes
No, I'll connect with a therapist on my own.
Your doctor's name
Your answer
Your doctor's number
Your answer
Does your doctor know you are seeking treatment of this nature?
*
Yes
No
N/A
You will be asked to provide a reading of baseline vitals from your doctor's office or a walk in clinic before your medical consult with our physician. Is this possible for you?
*
Yes
Which payment option works for you?
*
Full payment at time of registration (ranging from $2100 - $3800)
Two instalments: 50% at time of registration, 50% before start of program
How did you find us?
*
Your answer
Thanks so much for completing the form! Please submit the form and we will be contacting you shortly. - the Katalyst team
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