MINI KETAMINE EVAL

What is your name?* This field is required.

First Name

Last Name

Phone Number* This field is required.

Area Code

Phone Number

Email* This field is required.

example@example.com

What are you looking to accomplish?* This field is required.

Improved well being

Improve my relationship with myself

Improve my relationship with others

Heal from trauma(s)

Find peace and acceptance within

Process emotions / connect with emotions

Find purpose

Learn tools to help myself

Become more vulnerable

Improve Confidence

Increase motivation

Other

Have you been struggling with any of the following?* This field is required.

Decreased Motivation

Poor/Negative self talk

Inability/Decreased ability to focus

Low affect / mood

Low energy

Irritability

Poor sleep quality or duration

Excessive worry

Chronic Pain

Obsessive and/or intrusive thoughts

Inability / Diminished ability to control emotions

None of the above

Other

In clinical studies, Ketamine has been indicated to be useful for the treatment of depression, anxiety, PTSD, chronic pain, and even stress reduction.

For depression, and anxiety Ketamine has been demonstrated to be more effective than traditional antidepressants for some patients.

Psychedelic therapies are shown to be powerful tools for healing and insight.

Ketamine has been an FDA-approved anesthetic that has been used since the 1970s, often being utilized for surgeries in children and seniors due to its high tolerability and not impacting respiration

Today, it is commonly used off-label for the treatment of many mental-related conditions.

Have you considered or received ketamine treatment in the past?* This field is required.

Yes, but I decided to wait

Yes, but it was too costly

Yes, and I've received Ketamine treatment before

No, but my provider recommended it

No, but I've read about the potential benefits

No, but. a family/loved one recommended it

None of the above

Other

Quintessence provides multiple modes of receiving Ketamine Therapy with options for varying budgets.

We provide IV Ketamine infusions at our clinic, located in Draper, Utah.

Can't make the commute? You also have the option to have your treatments shipped directly to you with our in-home Ketamine Therapy, Lifebox!

Do any of the following apply to you?* This field is required.Ketamine treatments are not for everyone. If you are in a life-threatening situation, call the National Suicide Prevention Line at +1-800-273-8255, call 911, or go to the nearest emergency room.

Under the age of 18 years of age

Pregnant / Wanting to become pregnant / or Breastfeeding

Primary psychotic disorder (e.g. schizophrenia, psychotic disorder unspecified, etc)

Bipolar Disorder (currently experiencing mania)

Bipolar Disorder (currently experiencing depression or stable mood)

Recent drug addiction or substance abuse

Uncontrolled high blood pressure (Hypertension)

Uncontrolled seizures

Untreated / Uncontrolled Thyroid disease (e.g. hyperthyroidism)

History of stroke or heart attack

Require supplemental oxygen

History of heart disease (arrhythmias, congestive heart failure, coronary artery disease)

Liver disease

AV malformation or aneurysmal vascular disease

Active delusions and/or hallucinations

N/A

Other

How did you hear about us?

Word of Mouth

Facebook

Instagram

Google

Radio

Referred by a Physician

Referred by a Mental Health Professional

Other

Please list all prior and/or current Neurological/Brain conditions (stroke, epilepsy, concussions, TBI, etc.)* This field is required.

Now that we have some basic information, let us take some time to shape your Ketamine experience to your needs.

When it comes to learning and growing, which do you prefer?

I like to have a plan

I like to leave room for the unknown

I like to have a balance of both

When working with one of our treatment guides, what suites your needs the most?

A spiritual guide

An analytical guide

A bit of each

I'm unsure

Is there anything in particular that you would like to work on during your treatment?

Ketamine has been shown to expedite changes in the brain, with powerful effects on areas of the brain that control emotion, memory, and perception of the world around us. The goal is to provide a path for introspection, vulnerability, connection with your emotions, and growth within.

Learn more about how Ketamine may be able to help you and schedule a consultation with one of our providers!

Which treatment type are you interested in?

In clinic IV

In-home Lifebox

I need some more info

What area are you currently located in?

If you will plan to be using insurance to pay for this treatment please upload a copy of your insurance card below. Accepted insurances include BCBS (all blue cross blue shield plans), Cigna, UHC.*Please note that this is not a guarantee that insurance will cover the cost of ketamine treatments.*

Please list times you have available for someone to reach out to provide information regarding our ketamine treatment, and to get you scheduled with a medical evaluation to see if you qualify.* This field is required.

Have you talked to your PCP about your condition?

YESNO

Have you tried other treatments in the past for your condition?

YESNO