Sliding Scale KAP Therapy Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Are you seeking treatment in Austin or San Antonio
Austin
San Antonio
What are you seeking treatment for?
*
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?
*
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?
*
Please upload your most current W2 tax return.
*
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Please upload your most recent check stub.
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