Thank you for your interest in Healing Realms Ketamine Assisted Psychotherapy (KAP) services.  Please read the following information about our waiting list status, process and this form.

Update for February 2022: We are currently accepting new clients off of the waiting list and will email you with further instructions when we have a spot for you to schedule a new client phone consultation.

Upon completion of this form, you will be placed on our KAP waiting list and we will reach out to schedule an initial phone call to answer any questions you might have, and to help determine if Ketamine Assisted Psychotherapy might be an appropriate intervention for you at this time.

NOTE: This form is not to be used for urgent requests or emergencies. If you are experiencing an emergency, please call 911 or go to your nearest emergency room.