PRE-SCREENING &
INTAKE FORMS


KETAMINE INFUSION PRE-SCREENING & INTAKE FORMS

Prior to beginning your ketamine infusions, it is important for us to understand and evaluate your level of depression and/or anxiety. This helps us identify any other conditions that may complicate your treatments, or render them ineffective.

Please review our Privacy Practices and complete the following forms prior to your first treatment:

HIPAA Acknowledgement

Patient Intake Form

Ketamine Treatment Consent

Acknowledgement of Ongoing Care (to be completed by a referring physician or mental healthcare provider)