Tell us about yourself
Initial Practitioner Survey
Full Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Country
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State
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Alabama
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Vermont
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West Virginia
Wisconsin
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Let's get started
We’d love to learn more about you to get you started as a clinician doing Ketamine Enhanced Psychotherapy (KEP). This initial clinician survey takes approximately 3 minutes to complete.
Do you currently have a private practice?
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No
Yes, I’ve been in private practice under a year
Yes, I’ve been in private practice for a year to 5 years
Yes, I’ve been in private practice for 5 to 10 years
Yes, I’ve been in private practice for over 10 years
If you are in private practice, how many clients do you see weekly?
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I am not in a private practice
0-5
6-10
11-15
16-20
20+
Have you experienced ketamine before?
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No
Yes, a few times
Yes, more than a few times
Yes, I’m very experienced with ketamine
I do not wish to answer
Have you experienced other psychedelics besides ketamine before?
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No
Yes, a few times
Yes, more than a few times
Yes, I’m very experienced with psychedelics
I do not wish to answer
Are you currently licensed in the state(s) in which you are practicing?
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Yes - please list state(s) and license number in field below.
No
No, but I am working on becoming licensed. Please provide date you expect to be licensed in field below.
Please list state(s) and license number, or alternatively the date you expect to be licensed
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Have you ever practiced psychedelic enhanced psychotherapy?
No
Yes, a few times
Yes, more than a few times
Yes, I’m very experienced as a psychedelic enhanced psychotherapist
If you are a prescriber, have you ever prescribed ketamine for (KEP) before?
I am not a prescriber
Yes, a few times
Yes, more than a few times
Yes, I’m very experienced at prescribing ketamine for KEP
What treatment modalities do you practice the most as a therapist? Choose up to 3
I am not a therapist
Acceptance and Commitment (ACT)
Adlerian
Applied Behavioral Analysis
Art Therapy
Attachment-based
Biofeedback
Brainspotting
Christian Counseling
Clinical Supervision and Licensed Supervisors -
Coaching
Cognitive Behavioral (CBT)
Cognitive Processing (CPT)
Compassion Focused
Culturally Sensitive
Dance/Movement Therapy
Dialectical (DBT)
Eclectic
EMDR
Emotionally Focused
Energy Psychology
Existential
Experiential Therapy
Exposure Response Prevention
Expressive Arts
Family / Marital
Family Systems
Feminist
Forensic Psychology
Gestalt
Gottman Method
Humanistic
Hypnotherapy
Imago
Integrative
Internal Family Systems (IFS)
Interpersonal
Intervention
Jungian
Mindfulness-Based Cognitive Therapy
Mindfulness-Based Somatic Therapy
Motivational Interviewing
Music Therapy
Narrative
Neuro-Linguistic
Neurofeedback
Person-Centered
Play Therapy
Positive Psychology
Prolonged Exposure Therapy
Psychoanalytic
Psychobiological Approach Couple Therapy
Psychodynamic
Psychological Testing and Evaluation
Rational Emotive Behavior (REBT)
Reality Therapy
Relational
Sandplay
Schema Therapy
Solution Focused Brief (SFBT)
Somatic
Strength-Based
Structural Family Therapy
Transpersonal
Trauma Focused
Other Treatment Orientation
Have you ever had a disciplinary action filed against you by a regulatory agency?
No
Yes
If yes, please explain disciplinary action and outcome
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Which mental health issues do you specialize in treating? Choose up to 3
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Addiction
ADHD
Adoption
Alcohol Use
Alzheimer's
Anger Management
Antisocial Personality Disorder
Anxiety
Asperger’s
Autism
Behavioral Issues
Bipolar Disorder
Bisexual
Borderline Personality
Career Counseling
Child and Adolescent
Chronic Illness
Chronic Impulsivity
Chronic Pain
Chronic Relapse
Codependency
Coping Skills
Depression
Developmental Disorders
Divorce
Domestic Abuse
Domestic Violence
Dissociative Disorders
Dual Diagnosis
Eating Disorders
Elderly Persons Disorders
Emotional Disturbance
Family Conflict
Gender Dysphoria
Gambling
Grief
Hoarding
Impulse Control Disorders
Infertility
Infidelity
Intellectual Disability
Internet Addiction
Learning Disabilities
Life Coaching
Life Transitions
Marital and Premarital
Medical Detox
Medication Management
Men's Issues
Mood Disorders
Narcissistic Personality
Obesity
Obsessive Compulsive Disorder (OCD)
Oppositional Defiance
Parenting
Peer Relationships
Personality Disorders
Pregnancy, Prenatal, Postpartum
Psychosis
Racial Identity
Relationship Issues
School Issues
Self-Harming
Self Esteem
Sex Therapy
Sexual Abuse
Sexual Addiction
Sleep or Insomnia
Spirituality
Sports Performance
Stress
Substance Use
Suicidal Ideation
Teen Violence
Testing and Evaluation
Thinking Disorders
Trauma and PTSD
Traumatic Brain Injury
Video Game Addiction
Weight Loss
Women's Issues
Other Issues
Do you speak another language?
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None other than English
Arabic
Armenian
ASL
Bosnian
Cantonese
Creole
Croatian
Dutch
Farsi
Filipino
French
German
Greek
Gujarati
Hebrew
Hindi
Hungarian
Italian
Japanese
Korean
Mandarin
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian
Sinhalese
Spanish
Swedish
Turkish
Ukrainian
Urdu
Vietnamese
Yiddish
Other Language
When are you available for sessions?
Monday
Tuesday
Wednesday
Thursday
Friday
Sunday
Early AM (7-9)
Late AM (9-12)
Early PM (12-3)
Late PM (3-6)
Evening (6-9)
How many hour long sessions per week would you like?
0-5
6-10
11-15
16-20
20+
Please upload your Resume in .pdf, .doc, or .docx format
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