What Brings You Here
You don’t have to explain everything — just share what feels most present.
What are you struggling with right now? (check all that apply)
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Anxiety
Depression
PTSD or past trauma
Grief
Burnout
Emotional numbness
Loss of motivation or purpose
Other (please specify)
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What have your tried to feel better? (check all that apply)
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Therapy
Medication
Psychedelic/ketamine sessions
Meditation or mindfulness
Nothing has worked
Other (please specify)
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96% of our clients experience positive benefits. Which outcomes are most important to you? (check all that apply)
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Reset brain & nervous system
Improved mood
Increased energy & motivation
Better brain functioning
Relaxation & peace of mind
Deeper sleep
Release of trauma
Reduced stress
Reduced pain in the body
Less intense emotions
Greater spiritual connection
Other (please specify)
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What feels hardest about your current experience?
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Why do you feel ready — or at least willing — to take this next step?
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Making Sure It’s a Match
Just a few quick questions to make sure this is the right support at the right time.
How long has this been affecting your life?
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Less than 6 months
6–12 months
1–3 years
More than 3 years
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Have you ever completed a ketamine program before (clinical or at-home)?
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Yes
No
Sort of — I’ve done a few sessions but not a full protocol
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Are you more drawn to:
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A fully guided reset with coaching
A low-touch, do-it-yourself protocol
Not sure yet
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How important is it to you to heal without becoming dependent on long-term medication or treatments?
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Very important — that’s why I’m here
Somewhat important
Not a priority for me
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If accepted, are you ready to begin right away to secure one of the 10 discounted spots for this enrollment period?
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Yes, I'm ready to move forward if offered a spot
I'm interested, but might need a little more time
I'm not sure yet—I have some questions
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If accepted, how would you plan to move forward?
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Full pay with discounted spot ($777–$1111 depending on program)
Payment plan (starting at $444)
Not sure yet
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Are you aware that this program is not covered by insurance and is a private-pay investment?
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Yes — I understand and I’m still interested
I wasn’t sure, but that makes sense
I was hoping to use insurance, so I may need to pause
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If accepted, will you be available to book a short 15-minute call with us?
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Yes
No
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We can’t work with everyone — and we’re intentional about who we support. Why do you feel you’d be a strong fit for this program?
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Last question - do any of the following apply to you?
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Under 18 years old
Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder)
Prepared for or attempted to end your life (in the past year)
Biological female who is pregnant, nursing, or trying to become pregnant
Uncontrolled high blood pressure
History of bipolar 1
Currently in pain management
None of the above
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You're almost there. Let’s lock in your next step.
Thanks for completing your application — we just need to confirm a few details and get your 15-minute connection call scheduled. This call is your space to ask questions, feel into which option is right for you, and explore next steps together.
Confirm Name
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Confirm Email
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example@example.com
How did you hear about us?
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Please Select
Google
Facebook
Instagram
Referral
Will you schedule your 15-minute call on the next page?
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Please Select
Yes, I will schedule on the next page.
We keep this call very low pressure — so you can move forward with clarity.
Schedule 15-Minute Call
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