KAP Interest Form Ketamine Assisted Psychotherapy Interest Form Name * First Last * Last Phone * Email * * I understand that Ketamine Assisted Psychotherapy involves a significant time and financial commitment. By checking the box, I understand that participating in the KAP program at The Catalyst Center will likely involve a time commitment of 8 or more hours per week for three consecutive weeks and cost between $4000 and $6500 depending on the level of therapeutic involvement in my case. I also understand I will not able able to drive myself home from my ketamine sessions and will need to take the rest of the day off from work or other significant responsibilities on days when I am administered ketamine.* How did you hear about Ketamine Assisted Psychotherapy? * Why are you interested in Ketamine Assisted Psychotherapy? * Do you currently work with a mental health provider? (Therapist, psychiatrist, psychiatric nurse practitioner, etc.?) * Yes No If yes, please describe. Do you have any previous experience with psychedelics? * Yes No Prefer not to answer If yes, please describe your experience. Briefly explain your current mental health concerns. * We are committed to safety in our KAP program. Please select any of the following that apply to you as they will warrant a longer conversation about whether KAP is appropriate for you. * Pregnant and/or nursing Hypertension or other cardiovascular problem Hyperthyroidism Active Mania/Hypomania History of Psychosis or Schizophrenia Allergy to ketamine or past addiction to ketamine Recent Traumatic Brain Injury Severe Obstructive Sleep Apnea or Respiratory Disease An ongoing substance use disorder or addiction None of the above If you are human, leave this field blank. Submit
