Substance Use and Sobriety Agreement

Substance Use and Sobriety Agreement

To ensure your safety and optimize the benefits of Ketamine-Assisted Psychotherapy (KAP), we ask you to adhere to the following agreements regarding substance use and sobriety.
Client Name*

First NameLast Name
Alcohol
I agree to abstain from consuming alcohol for at least 24 hours before and after my ketamine medicine sessions.
Client Confirmation*

I understand and agree.
Client Initials*
Benzodiazepines and Other Medications
I agree to inform my clinician of all medications I am taking and to avoid benzodiazepines (e.g., Xanax, Ativan) and other sedatives unless approved by my prescribing physician and the Temenos medical team.
Client Confirmation*

I understand and agree.
Client Initials*
Substance Use
I agree to disclose any use of recreational drugs or substances, including cannabis, prior to starting treatment.

I understand that the use of substances may interfere with the safety and efficacy of ketamine treatment.
Client Confirmation*

I understand and agree.
Client Initials*
Should be Empty:

Alcohol