Recovering From Sexual Trauma

Provide information to gain early access to The Recovering From Sexual Trauma Ketamine Therapy treatment package
Name*

First NameLast Name
E-mail*
Phone Number*
How familiar are you with ketamine or psychedelic therapy?*

Very FamiliarSomewhat FamiliarNot at all
Which state do you live in?*
What is your age range?*

18-2425-2930-3435-3940-4445-4950-5455-5960+
Preferred way to contact*

PhoneEmailTextAny
Best time of day to contact

MorningAfternoonEvening
Do you have any questions about the program?
Thank you for your interest!

If you’re in a crisis, reach out immediately to any of the organizations below. Many of them have texting or online chat services as well if you can’t make a phone call. Rape, Abuse & Incest National Network (RAIN) National Sexual Assault Hotline, 1-800-656-HOPE (4673)
Should be Empty:

Provide information to gain early access to The Recovering From Sexual Trauma Ketamine Therapy treatment package