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Ketamine Treatment Inquiry

Estimated time to complete: 5-10 minutes


What to expect

The first step towards applying for Ketamine treatment is to complete this form, which screens for medical issues that may impact or prevent Ketamine use. Once you have completed this form and our ARNPs have reviewed it, we will contact you to schedule a psych eval appointment when an opening in our Ketamine treatment schedule is available. Note that we cannot guarantee an opening will be immediately available, or the length of time before an opening will occur. Once you have been approved for treatment and completed your evaluation appointment, including providing any updated information, you will be entered into the treatment schedule and given your session dates. You may be contacted by admin staff to provide you with additional information about your treatment, and how best to prepare for your upcoming sessions.

Insurance Benefits Information

Please note that if you plan to use health insurance, you should come to your first visit with your current insurance benefits information checked and confirmed as you may have a deductible to meet before treatment is covered by your plan. Some services we provide may not be covered by insurance - please check with us if you are not sure. We do not accept any EAP programs, United Health, CHPW, or Medicare.

Eligibility And Appointments

Completion of this form is not a guarantee that you will be approved for this treatment, nor that an appointment opening is currently available, or soon to be available. If you are eligible and there are no current open appointments available you may be placed on a waitlist and contacted when an appointment becomes available. This is a new treatment with promising benefits and there is high demand. We offer appointments on a first-come, first-served basis.

In order for us to provide safe and effective care, during your ARNP evaluation appointment you will be required to re-verify your submitted information to ensure it is up-to-date, as well as provide up-to-date vitals (you must obtain these from your primary care provider prior to your eval).

Confidentiality Of Submitted Form Information

Any information submitted using the form below will be encrypted before it is transmitted to our offices, where it is securely stored according to HIPAA regulations. Your confidential information is sent to us directly and is not stored unencrypted at any point in any third-party services or hosts.

Do not resubmit this form

Do not submit multiple versions of this form for the same client. Our system allows for only one profile per client, and your multiple intake submissions will ALL be put on-hold until admin staff has time to manually determine which of your submissions is the most accurate and therefore WILL significantly hold up your intake process. If you have previously submitted incorrect information, please call or email to update, giving your name and date and time of your submission.


This is only to aid Admin in verifying your chart. Your ketamine treatment providers may be different from your current/past providers.