Find Out if you Qualify for Ketamine Therapy

Please complete this safety screening form to ensure we provide the safest and most effective specialized services tailored to your needs.

IMPORTANT SAFETY NOTE
Certain medical conditions, medications, mental health histories, and other factors may affect eligibility for ketamine or psilocybin services. All patients must complete appropriate screening and receive approval from the applicable providers and/or facilitators before participating. This quiz does not determine eligibility. It is intended only as an educational planning tool.

Ketamine Safety Screening Form

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Name *

Email *

Phone Number *

Are you at least 17 years of age? *

• Yes
• No

Are you pregnant or nursing?

• Yes
• No

Do you have a known Ketamine allergy?

• Yes
• No

Are you currently being treated for a medical or mental health condition?

Are you currently being treated by a medical, clinical, or other healthcare provider for a medical, mental health, or behavioral health condition? If so, please leave a brief description.

ever Number or

Have you ever been diagnosed with or treated for psychosis?

• Yes
• No

Have you ever experienced any of the following:

• Uncontrolled Hypertension
• History of Psychosis
• Schizophrenia
• Mania or unstable bipolar disorder
• Brain Injury or aneurysm
• Allergy to Ketamine
• Recent stroke
• Dementia
• Seizures
• Sever Liver Disease
• Other (please explain below)

Please indicate if you have or have ever experienced any of the following health conditions.

What medications and supplements are you currently taking?

Please include anything you are currently taking or have discontinued within the past 90 days.

Comments or Explanations

I certify that the information above is accurate and current. *

• I agree
• I do not agree

I agree to update the staff immediately if my health status or physical condition changes before my appointment.

Schedule a chat or request a call

• Please email me
• Please call me
• Please text me to find a good time to talk
• I am not interested in pursuing Ketamine further at this time

Send