Ketamine Intake Form

Please answer these questions as thoroughly and completely as possible so Dr. Reeves can review before your phone consultation. This information is confidential, and Dr. Reeves will NOT reach out to any individuals without your permission.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthday

Date

Drug Allergies:

Medications/Supplements (provide doses if possible):

Primary Care Provider/Family Doctor:

Psychiatrist:

Counselor/Therapist:

Medical Problems (examples: high blood pressure, asthma, low thyroid, etc.):

Mental Health Diagnosis for which you are looking to treat with Ketamine Therapy: (examples: Depression, generalized anxiety disorder, Major Depressive disorder, Post traumatic stress disorder, obsessive compulsive disorder, anorexia, bulimia, chronic neuropathic pain, fibromyalgia, substance abuse)

Do you ever have thoughts of hurting yourself? If yes, do you have a plan to hurt yourself?

Have you ever intentionally tried hurting yourself or ending your life?

Have you ever been hospitalized for your mental health condition? If yes, when?

What therapies or medications have you tried that have not worked? (Examples: SSRIs, TMS, ECT, counseling)

Are you actively using any recreational drugs?

Do you have a history of alcohol or substance abuse?

Do you have a history of trauma or childhood trauma?

Have you ever had auditory or visual hallucinations, or have you ever been diagnosed with schizophrenia?

Do you have any of the following: Uncontrolled high blood pressure, glaucoma, history of brain mass or elevated brain pressure, active mania or manic thoughts, kidney or liver problems, history of heart of failure, oxygen dependent? Please let us know if any of these are pertinent as they would make Ketamine therapy potentially dangerous?

Are you interested in meeting with one of our therapists to potentially explore Ketamine Assisted Psychotherapy?

Have you ever had a psychedelic experience with ketamine, NMDA or psilocybin ("magic mushrooms")

Ketamine Intake Questionnaire/History