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.
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?

I'm just getting started1 year2-4 years5 plus years
Professional Information
Your Specialty

NeurologistPain SpecialistPsychologistPsychiatristPrimary Care PhysicianSocial WorkerLife/Executive CoachOther
Education/Degrees

BA/BSMA/MSPhDOther
What kind of professional license(s) do you have?

Medical DoctorMarriage & Family TherapistNaturopathic DoctorNurse PractitionerOsteopathic PhysicianPhysician AssistantProfessional Clinical CounselorPsychiatristPsychologistRegistered NurseOther
What is your license number?
Do you have professional liability and general liability insurance?

YesNo
Please upload a picture of your insurance policy coverage page

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

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

KetaminePsilocybinLSDMDMADMTAyahuascaOther
How much experience do you have providing KAP?

Just getting started1 year2-4 years5 plus years
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?

weeklymonthlyquarterlyyearly
Reasons for working with us?

I need a medical license in order to provide Ketamine legallyI want to offer my patients IV Ketamine treatments (vs oral or intramuscular administration)I want to offer my patients other infusion therapies in addition to Ketamine (NAD, Glutathione, Vitamins, etc.)I need a suitable space to offer KAPI want professional/clinical expertise so I feel more confident providing KAPI want someone else to handle the administrative/legal issuesOther
How soon would you like to start?

As soon as possible (Critical/Emergent)Some time in the next week (Urgent)Some time in the next 2 weeks (Somewhat Urgent)Some time this month (Soon)Some time in the next 3 months (Not Urgent)
How did you find out about us?

A colleague/healthcare professional told me about youMy patient told me about youA friend/personal contact told me about youI did a Google/search engine searchI found you on social media (Facebook, LinkedIn, etc.)I found you in online listings (Google, Yelp, Apple Maps, etc.)I saw an online advertisement/linkOther
Should be Empty:

Ketamine Assisted Psychotherapy (KAP) Provider Questionnaire

Contact Information

About Your Business/Practice

Professional Information

Experience with Psychedelics/Ketamine

Additional Information