AIMS Group KAP Interest Form

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Please fill this out to indicate your interest in AIMS Group KAP offerings. This will help us to collect the information that we need and create groups specific to the needs and interests of our patients. By filling this out you agree to be contacted to follow up on your response.

Email *

Name *

Date of Birth *

YYYY

Which of the group KAP offerings are you interested in? Select all that apply. *

Drop-in Fridays (open to patients who already have experience using Ketamine at AIMS).

Closed group, multi-week themed group KAP (open to new and existing patients)

Intro to Ketamine troches and a home-based program (open to patients who have experience with using Ketamine in a clinical/therapeutic context at AIMS or another similar clinic)

Required

What is your experience with ketamine? Select all that apply. *

Never used ketamine therapeutically

Have received sublingual (SL) ketamine therapeutically (troches/lozenges/oral liquid)

Have received intramuscular (IM) ketamine therapeutically

Have received intranasal (IN) ketamine therapeutically

Have received intravenous (IV) ketamine therapeutically

Other:

Required

If 'other,' please describe the route and/or setting below.

If you are interested in the themed group KAP programs, which of the following focus areas align with your needs? Select all that apply.

Depression

Anxiety

Pain

Palliative Care

End of Life

Grief

Postpartum or perinatal mental health concerns

Disordered Eating

Religious Trauma

PTSD and cPTSD

Other:

If 'other', what other group theme(s) are you looking for?

Our team will be in touch with you shortly. What is your preferred phone number for scheduling? *

What is your preferred email address? *

How did you hear about the KAP program at AIMS?

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