The Intensive Reset - Initial Application

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Name* This field is required.Name of client seeking The Intensive Reset
First Name
Last Name
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Is this you?* This field is required.
YESNO
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If no, please let us know your name and relationship to the person seeking therapy. Due to HIPAA laws, we are unable to accept applications for adults completing this form on behalf of another adult. If the individual seeking services is 18 years of age or older, they need to complete the form themselves. Failure to follow these instructions will result in dismissal of your application. First Name * Last Name * Relationship *
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PronounsPronouns of client seeking The Intensive Reset
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Date of Birth* This field is required.Enter the date of birth for the individual seeking services (yourself or adolescent minor, must be at least 12 years old)
Date
Month
Day
Year
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Email* This field is required.Best email address to contact you
example@example.com
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I'd like occasional resource articles and company alerts sent to this email address:* This field is required.
YESNO
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Phone Number* This field is required.Best phone number to contact you
Please enter a valid phone number.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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How did you hear about us?* This field is required.
Google
Instagram
Facebook
Psychology Today
Healthcare Provider Referral
Friend/Family Referral
School Referral
Current Reset client
Other
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If you are a current client, did you discuss this program with your Reset therapist?
YESNO
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Preferred Reset Location* This field is required.
Plymouth
Northville
Ann Arbor
Virtual
Any
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Availability* This field is required.What is the potential client's schedule availability? *Please indicate all possibilities
Morning (8-11am)
Afternoon (noon-4pm)
Evening (after 5pm)
Weekends (Saturday and Sunday)
Flexible, first available
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Goals* This field is required.What brings you to explore an Intensive Therapeutic Reset at this time? Feel free to share any personal, emotional, or life challenges you’re facing, goals and what you'd like to work through in this program.
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Ok
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Have you had previous experience with therapy or personal growth programs?* This field is required.If yes, please provide a brief overview and any diagnoses.
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Are you currently in crisis or experiencing acute mental health challenges?* This field is required.If yes, please note: Reset Brain and Body is not a mental health crisis center. Do not use this form in case of emergency or if you or your adolescent are feeling suicidal. Instead, please call 911 or 988, go to your nearest emergency room, or contact the national suicide hotline at 800-273-TALK (8255). Visit: www.resetbrainandbody.com/emergency-resources
No, I am not currently in crisis or experiencing acute mental health challenges.
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Our Intensive Reset involves deep self-exploration and experiential therapies that may bring up difficult emotions. Do you have a support system in place (friends, family, or professionals) to help you integrate after the experience? * This field is required.If yes, please describe your support network.
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Are you interested in participating in the optional Ketamine-Assisted Psychotherapy component of the Intensive Reset?* This field is required.
Yes
No
Maybe
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If yes or maybe, why are you interested in integrating Ketamine into your experience?
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Do you have any medical conditions or take medications that may contraindicate the use of Ketamine? If yes, please describe.Exclusionary Conditions would include: Active substance abuse (Alcohol, cannabis, non-prescribed medications, etc.), History of psychosis, History of increased intracranial pressure, Pregnancy (current), Uncontrolled hypertension, Acute or unstable cardiovascular disease, Previous negative response to ketamine.
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Have you had any previous experience with psychedelics, including Ketamine? If yes, please share your experience.
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Good Fit Consultation Disclaimer and Consent* This field is required.Please note your understanding of the following: We understand that each individual has unique needs, goals, and circumstances when it comes to their mental health journey. While intensive therapy programs can be highly effective for many, they aren't always the best fit for everyone. Some individuals may benefit more from a different level of care, such as outpatient therapy or other types of support, based on factors like their readiness for an intensive approach, the specific challenges they’re facing, or their current life circumstances. Our goal is to ensure that every person receives the care that is best suited to them. If this program doesn’t feel like the right fit for you based on this application or the Good Fit Consultation, we’re here to guide you toward other resources or approaches that align better with your needs.
Yes, I understand that filling out this application does not automatically guarantee my participation in the program
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Self-Pay Disclaimer and Consent* This field is required.Our Intensive Therapeutic Reset is a self-pay service and is most likely not covered by insurance. By submitting this application, you acknowledge that you are responsible for covering the costs of the program out-of-pocket. (Exception for medical fees related to the optional ketamine-assisted psychotherapy component.)
I understand and consent that this program is self-pay and will not be billed through insurance, nor will I submit for insurance reimbursement
I'd like to discuss payment options before I consent.
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On a scale from 1-5, how ready are you to really dig in and do the deep work to overcome your limits and obstacles to get you to the next level?* This field is required.1 indicating not very ready whereas 5 is very ready
1 Not very ready
2 Not ready
3 Somewhat ready
4 Ready
5 Very ready
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Additional InformationIs there anything else we should know before considering you for this program?
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