KAP Pre-Screening Form
This form is used to determine your eligibility for Ketamine Assisted Therapy. Please fill it out and Danielle will reach out to you within 24-48 hours. Thank you!
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Name *
Which State do you reside in? *
Email : *
Phone Number *
What problems or struggles are you hoping to work through with KAP?

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Are you currently seeing a therapist regularly? If yes, please share their name. 
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Do you have a known allergy to Ketamine?*
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Have you ever received a diagnosis of bipolar disorder, dissociative disorder, a personality disorder (i.e schizophrenia, borderline personality disorder) or psychosis? If yes, please explain which one(s) and the approximate date of when you received the diagnosis.
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Do you now, or have you in the past, struggled with substance or addiction? If yes, please share if the addiction is present or in the past
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Do you have a complex Trauma History? Complex trauma is defined as a series of traumatic events that take place over a long period of time. Can be months or years.
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Have you ever had experiences of non-ordinary or altered states of consciousness? How was the experience for you?
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Do you have any questions/ concerns about KAP?
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