Please submit for ketamine appointments only

First and last name:

Phone

Date of birth

List or describe any diagnoses that you currently have or have had: Major Depressive Disorder, • Post-Traumatic Stress Disorder, • Bipolar Disorder, • Anxiety or Panic Attacks/Disorders, • Autism Spectrum Disorder, • Schizophrenia, • Schizoaffective Disorder • List any other current or past psychological or mental/emotional health conditions for which you needed treatment:

List ALL medications and doses you are currently taking

Please list or describe any medical issues such as liver or kidney issues, thyroid concerns, cardiovascular concersn such as stroke, heart attack and high blood pressure

Why are you interested in ketamine? What would you like to gain from ketamine sessions?

Have you been hospitalized before for mental health issues?Why were you hospitalized?

Do you have any history of substance use including alcohol? What substance have you used/ currently using?

Please read all information contained on our ketamine page including the process, time required and costs. Please allow 3 business days for a return call

Thanks for submitting!

Daya
Mental Health & Wellness

New Ketamine Client Questionnaire

Please submit for ketamine appointments only

Please read all information contained on our ketamine page including the process, time required and costs. Please allow 3 business days for a return call

(828) 412-3330
(828) 778-2973