CMAT Suitability Questionaire

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Your Full Name* This field is required.
First Name
Last Name
2
Your Email* This field is required.
example@example.com
3
Your Phone Number* This field is required.
Area Code
Phone Number
4
Please verify you are a human* This field is required.
5
How did you find out about CMAT?* This field is required.
Please Select
Please Select
My healthcare providers (eg. Therapist, Primary Care Provider, Social Worker, etc)
Coach
Google
Social Media
Word of mouth/friend
Other
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Optional: Who is your Healthcare Provider? (First and Last Name)
First Name
Last Name
7
Optional: What is their contact information? (Email or Phone)
example@example.com
8
Do you meet the following eligibility criteria?You must meet ALL of the following criteria in order to access our Medicine Assisted Therapy services. I am a resident of Canada I am an adult aged 18 years or older I am interested in applying for Medicine Assisted Therapy for myself
YESNO
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Are you aware that individuals with the following health conditions are not eligible for Medicine Assisted Therapies?Untreated high blood pressure Unstable cardiovascular disease (e.g. recent or untreated heart attack or stroke) Uncontrolled thyroid disorder Pregnancy Active/unstable seizure disorder Advanced/severe liver or kidney disease Acute angle glaucoma
YESNO
10
Are you aware that individuals with any of the following psychological or environmental conditions are not eligible for Medicine Assisted Therapies?Individuals experiencing psychosis or with a history of a psychotic disorder Individuals with active substance use disorder (currently unable to control use of alcohol, cocaine or other methamphetamines, opiates, or benzodiazepines) Individuals with severe borderline personality disorder and who have not completed Dialectical Behavioural Therapy (DBT) Individuals incapable of medical decision making, who would rely upon a family member or other qualified power of attorney for healthcare decision making Individuals in unstable living circumstances (currently homeless, or in an unsafe physical or social environment).
YESNO
11
I understand that Medicine Assisted Therapies are private pay, and I have the means to pay privatelyCost of treatment is $300-$350/treatment hour and is not currently covered under provincial healthcare plans. All medicine dosing sessions are conducted in-person in Vancouver, BC while some preparation and integration sessions may be virtual. Ketamine Assisted Therapy: 10-18 treatment hours [$300-$360/treatment hour] Psilocybin Assisted Therapy: 18-30 treatment hours [$300-$360/treatment hour] MDMA Assisted Therapy: 30-50 treatment hours with 2 therapists [$600/treatment hour] *Limited third party private insurance may be applicable to some of the costs.
YESNO
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I have the means to pay privately for Medicine Assisted Therapies which costs at minimum ~$3,500 for an initial treatment plan.
YESNO
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Which medicines are you interested in accessing?*All treatments with MDMA or Psilocybin are based on approval through Health Canada’s Special Access Program.
Ketamine Assisted Therapy [may treat a variety of conditions]
*MDMA Assisted Therapy [for severe treatment resistant Post-Traumatic Stress Disorder]
*Psilocybin Assisted Therapy [for severe treatment resistant depression or depression/anxiety associated with a life-threatening illness]
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Are you aware that Ketamine Assisted Therapy is ideal for individuals with one one of the following conditions:Post-Traumatic Stress Symptoms (PTSS) or Post Traumatic Stress Disorder (PTSD) Mood Disorder: Depression and/or Anxiety Stress and Burnout Obsessive Compulsive Disorder or Obsessive Compulsive personality traits Chronic pain Behavioural Addiction (e.g. sex, gambling, eating disorder) Alcohol or Drug Addiction IN STABLE SOBRIETY for minimum period of 4 weeks
YESNO
15
I am aware of the following eligibility criteria for Health Canada's Special Access Program for MDMA Assisted Therapy:Individuals diagnosed by a Psychiatrist or Medical Doctor with Post Traumatic Stress Disorder Individuals with PTSD symptoms that are severe and/or life threatening Individuals that have tried at least two first-line pharmaceutical treatments for PTSD (e.g. Sertraline/Zoloft, Paroxetine/Paxil, or Venlafaxine/Effexor) and could not tolerate these treatments OR these treatments were not effective at managing my PTSD symptoms Individuals that have tried evidence-based psychotherapy for PTSD (e.g. Cognitive Processing Therapy, EMDR, Cognitive Behavioural Therapy) and could not tolerate these treatments OR these treatments were not effective at managing my PTSD symptoms
YESNO
16
I am aware of the following screening criteria for Health Canada's Special Access Program for Psilocybin Assisted Therapy:Individuals who been diagnosed by a Psychiatrist or Medical Doctor with depression with severe and/or life threatening symptoms OR symptoms are associated with a life-threatening illness Individuals who have tried at least two first line pharmaceutical drugs from different classes for depression (e.g. SSRI such as Escitalopram/Cipralex, Fluoxetine/Prozac, Sertraline/Zoloft, Paroxetine/Paxil, Vortioxetine/Trintellix; SNRI such as Venlafaxine/Effexor, Desvenlafaxine/Pristiq; other such as Buproprion/Wellbutrin or Mirtazapine/Remuron) AND could not tolerate these treatments OR these treatments were not effective at managing my depression or depression/anxiety associated with life-threatening illness Individuals who have tried evidence-based psychotherapy for depression (e.g. Cognitive Behavioral Therapy, Interpersonal Therapy, other types of therapy) AND could not tolerate these treatments OR these treatments were not effective
YESNO
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I understand the Health Canada SAP process & timeline and have the means to pay for the application processFlat fee of $800 for the application process.
YESNO
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I attest that the information I have provided is true, accurate and complete to the best of my knowledge.
YESNO
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If you interested in being contacted if there are changes to our costs, suitability or services, please mark yes below
YESNO
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Please mark yes below if you would like us to contact you if there are changes to our costs or suitability criteria.
YESNO
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Optional: Do you self-identify as belonging to a marginalized demographic group?
BIPOC
LGBTQIA2S+
Female body
New immigrant or English as a second language
Person with a Permanent Disability (PWD)
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Optional: Is there anything else you would like to share with our team?
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Ok
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