Ketamine Assisted Psychotherapy (KAP) Provider Questionnaire

Ketamine Assisted Psychotherapy (KAP) Provider Questionnaire

TIME NEEDED TO FILL OUT THIS FORM: less than 10 minutes
Thank you for your interest in using our facilities and services to provide KAP to your clients.

Please provide the following information about yourself and your practice. We will call you (typically within 48 hours) after we have had the opportunity to review your information.

We look forward to working with you!
Contact Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
About Your Business/Practice
Business/Practice Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
How long have you been in business?
Professional Information
Your Specialty

Other
Education/Degrees
What kind of professional license(s) do you have?

Other
What is your license number?
Do you have professional liability and general liability insurance?
Please upload a picture of your insurance policy coverage page

Cancelof
Experience with Psychedelics/Ketamine
Which psychedelic medicines have you personally used?

Other
Which psychedelic medicines have you used in a professional capacity?

Other
How much experience do you have providing KAP?
Describe any KAP-specific trainings you have completed (when and with whom?)
Why do you provide KAP to patients?
please provide some insight into both personal and professional motivations for offering this type of treatment to your patients
Additional Information
How frequently are you anticipating treating patients/clients at our clinic?
Reasons for working with us?

Other
How soon would you like to start?
How did you find out about us?

Other
Should be Empty:

Ketamine Assisted Psychotherapy (KAP) Provider Questionnaire

Contact Information

About Your Business/Practice

Professional Information

Experience with Psychedelics/Ketamine

Additional Information