The Heart Way KAP Screening Form
Full Name
*
First Name
Last Name
Pronouns?
Gender?
Phone Number
*
Email Address
*
example@example.com
How did you learn of this office?
*
Please Select
Health care provider
Client of Heart Way Counseling
Heart Way Counseling website
Mental Health Practitioner in Atlanta
Family friend
Word of mouth
Internet search
Instagram
Facebook
Psychology Today
Other
If other, please explain:
If you were referred by your healthcare provider, please provide us with their full name and address below (if not applicable write N/A):
*
What problems or struggles are you hoping to work through with KAP?
*
Are you currently seeing a therapist regularly? If yes, please share their name.
*
Are you taking any medications, and if so which ones?
*
Do you have a known allergy to Ketamine?
*
Yes
No
Do you have any health concerns, specifically regarding high blood pressure, heart, liver, bladder issues, sleep apnea, or glaucoma? If yes, please explain.
*
Are you currently pregnant or breastfeeding? If yes, please explain which one.
*
Have you ever received a diagnosis of bipolar disorder, dissociative disorder, a personality disorder, or psychosis? If yes, please explain which one(s).
*
Do you now, or have you in the past, struggled with substance or addiction? If yes, please share if the addiction is present or in the past.
*
Have you had a recent acute hospitalization? If yes, please explain what it was for.
*
Do you have a complex Trauma History?
*
Yes
No
Have you ever had experiences of non-ordinary or altered states of consciousness? How was the experience for you?
*
What questions do you have for the KAP Therapist?
Anything else we should know?
Submit
Should be Empty: