Ketamine-Assisted Psychotherapy Dosing Session
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Start time End time
Client
*
First Name
Last Name
Email
*
example@example.com
Driver and/or chaperone Name and phone number
Please select
90837
90847
In Office
Online
Other
DSM 5R
Dosing Session Checklist
Client signed Informed Consent
Review session requirements (drive home, no alcohol or other drugs 24 hours prior (excluding prescribed medications), no food and caffiene 4 hours prior)
Meet Chaperone (remote only)
Need to have blood pressure cuff (remote only)
Discuss specifics regarding consent to touch (therapist, chaperone)
Discussed consent to walk client to bathroom if necessary (therapist, chaperone)
Setting discussed
Mindset discussed
Intentions discussed
Comments on mental status including risk assessment
Blood pressure before
Intentions
Blood pressure after
Therapist notes on what was observed and/or done during client’s journey
Notes on client’s described experience
Post Dosing Interventions
Assessment of client’s physical state
Assessment of client’s emotional and mental state
Exploration of client beliefs, feelings, insights
Use of cognitive-behavioral therapy principles
Use of psychodynamic and/or narrative therapy
Mediated between parts of self
Therapeutic use of art, drawings, clay, etc
Assessment of clients readiness to go home
Discharge Instructions given
Integration Journal Prompts given
Other
First Integration Session Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Second Integration Session Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Any other comments:
Please sign this form
*
Date Signed
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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