Noma Therapy Assessment

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What brings you to Noma Therapy today?* This field is required.Select all that apply
I am experiencing depression
I am experiencing anxiety
I am experiencing trauma or PTSD
Other
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Where can we send information about your personalized Noma Therapy program?* This field is required.By clicking "Next" you acknowledge that you have read and agree to Noma Therapy's Terms of Use and Privacy Policy.
3
What state do you live in?* This field is required.Noma currently only operates in certain states
Colorado
Other
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Please enter your state below* This field is required.
5
What insurance do you have?* This field is required.We accept most major commercial and Medicaid insurance plans in Colorado
Please Select
Please Select
Aetna
Anthem Colorado / Elevance
Cigna
Colorado Access
Colorado Community Health Alliance
Denver Health
Health Colorado / Carelon
Medicare
Northeast Health Partners
Rocky Mountain Health Plans
TriWest
United Healthcare / Optum
Other
I do not have health insurance
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Please enter your insurance plan below* This field is required.
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Optional: Let's collect your insurance detailsWe'll run a benefits check to make sure that you're covered
Legal name
Member ID
Group number (if applicable)
Date of birth (we need this in order to check your insurance)
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Optional: Who is the primary insurance policy holder?
Self
Spouse
Child
Other
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Optional: Please upload your insurance cardThis will help us run a more accurate benefits check
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Do any of these apply to you?* This field is required.Ketamine isn't a fit for everyone. Please tell us a little more about your medical history
I am pregnant or trying to become pregnant
I have heart disease or uncontrolled high blood pressure
I have untreated thyroid disease
I am actively struggling with substance abuse
I take medication for ADHD or Chronic Pain
I have been diagnosed with schizophrenia or have a history of psychotic symptoms
None of the above
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How did you hear about Noma Therapy?* This field is required.
Online search
Healthcare provider
Facebook or Instagram
Word of mouth
Other
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Please enter the name of the healthcare provider that referred you
13
Who told you about Noma?
14
How did you find Noma Therapy online?Choose all that apply
Google or Bing
HealingMaps
Psychedelic.Support
Zocdoc
Other
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It looks like you could be a great fit for our program!

Your next step is to book a free 15-minute consultation with one of our trained guides.
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Based on your medical history, we need to speak to you determine if you are a good fit for our program.

Your next step is to book a free 15-minute consultation with one of our trained guides.
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