Ketamine-Assisted Psychotherapy Preliminary Screening Form

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Thanks for getting in touch!

In order to determine whether you can safely proceed with ketamine-assisted therapy, please answer the following questions honestly.

Email *

First Name *

Last Name *

Email *

Phone *

Address *

How did you hear about me?
*

Internet search

Word of mouth

Other:

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Contraindications

Ketamine is contraindicated for the health conditions listed below. If any of these apply to you, ketamine is not a safe treatment option for you.

Primary Psychotic or dissociative disorder
Hypomania or mania
Unstable angina (chest pain/heart disease)
Uncontrolled hyperthyroidism
Uncontrolled hypertension
Increased intracranial pressure
Evidence of liver disease
A previously demonstrated allergy to ketamine
Pregnancy

In addition, ketamine cannot be mixed with opiates. If you are taking anxiety medications such as benzodiazepines, pregabalin, or gabapentin, they may blunt the antidepressant effects of ketamine. We ask that you refrain from taking various medications and alcohol 48 hours before and after your medicine session. if this is problematic for you, please let us know, as this could preclude you from attending the group.

Those with a history of cystitis or other bladder issues may need to be cleared by urological consultation, due to the rare but potentially significant adverse effect of cystitis.

Have you been diagnosed with or treated for any of the above contraindications? *

Yes. Unfortunately this means you are ineligible for KAP with us as ketamine is currently not a safe treatment option for you.

No. Beth will be in touch by phone within the next week to further discuss KAP with you.

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