Name
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First Name
Last Name
Email
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Phone
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(###)
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If we're unable to reach you via email and a phone call, may we leave a voice message on the phone number that you provide?
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Yes
No
Would you like to be subscribed to our mailing list so you can receive SoundMind updates regarding events we host, free webinars and online content we release, and other aspects of our work?
Yes
No
What is your DOB?
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MM
DD
YYYY
Do you identify as any of these groups?
If you feel comfortable telling more about your identity, please do so here. For example, if you identify as LGBTQIA+ and specifically as transgender, or if you are neurodiverse and specifically dyslexic, please let us know here.
Check off which service you are interested in, when they become available at our center:
We have a few priority areas of treatment diagnoses. Do you fall under any of these categories? Check all that apply.
Why do you want psychedelic therapy? What are your intentions and hopes for this treatment?
COST OF TREATMENT: Currently, ketamine-assisted psychotherapy (KAP) isn't covered by insurance. We generally recommend individuals try at least a 3-session cycle of treatment, which costs $3800 and includes medical intake, a preparation session, 3 KAP sessions, and integration. Some patients benefit from 6+ KAP sessions (each additional KAP session is $1150), but these additional sessions are options. Note that if you come to only one session and then want to stop treatment for any reason, that is always your decision and we don't charge you for sessions not completed (one 4-hour ketamine session is $1150 plus $350 for the full medical intake and preparation session). We do offer a payment plan for the 3-session package (8 monthly payments of $475). We have a limited number of these to offer but please let us know if you'd require this. As we grow our clinic, we are limited in our capacity to provide full financial scholarships to reduce this cost. If this fee poses too much of a financial hardship, we ask you to reconsider this therapy at this time or ask to be put on our list for subsidized therapy. Please let us know if you have any questions about this.
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Have you been diagnosed or suspect you have any of the following:
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Do you have any other mental health diagnoses not on the list above?
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Have you had psychotherapy before? If yes, please describe type and length. If no, please type "no."
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Do you currently have a therapist? If so, how often do you speak to the therapist or coach?
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Are you currently taking any mental health medications? If so, which ones?
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Were you previously taking mental health medications that you no longer take? If yes, which ones?
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Do you have any heart conditions or high blood pressure? If so, how are you treating it?
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Do you drink alcohol? If so, how many drinks a week on average?
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