Sliding Scale KAP Therapy Form

Sliding Scale KAP Therapy Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you seeking treatment in Austin or San Antonio

AustinSan Antonio
What is your your current occupation? *
Do you have someone who can provide transportation to and from your treatments?*
Are you a Veteran?*
What is your current annual income?*
What is your current household income?*
How many children/dependents do you financially support?*
If you pay child support, how much per month? (put N/A if you do not pay child support.*
Are you open to undergo Ketamine Assisted Psychotherapy in group format?
Are you open to providing an honest review of your treatment after your have completed our process?
Is there anything else that you think would be helpful for us to know about your financial situation?
Please upload at least one of the following below : your most current tax return, most recent check stub, or both.

Please submit the income information of the person who will be responsible for the payment of your treatment.
Please upload your most current W2 tax return, last check stub, or other income statement.*

You can upload multiple documents here.
Cancelof
Should be Empty:

Please upload at least one of the following below : your most current tax return, most recent check stub, or both.