PSI Confidential Screening Form

Confidential Screening Form

Thank you for your interest in our clinical services and research programs. This form will help us determine the best options for you. All responses are HIPAA-protected.
Name*

First NameLast Name
Age*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Best Way to Reach You?*

Phone CallEmail
How did you hear about TRIP Clinics?

Search Engine (Google, Bing, etc).Provider ReferralSocial MediaFriend/ FamilyOther

You don’t need to have it all figured out. This is a place to ask questions, get clear answers, and see if treatment or a clinical trial might be right for you.

All responses are HIPAA-protected.
Please choose an option below

Ketamine-Assisted Psychotherapy (KAP)Psychedelic IntegrationClinical TrialsMedication ManagementPsychotherapyNot Sure

Thank you for your interest in our clinical studies. At PSI, participants are valued partners in advancing the science of psychedelic medicines. Our process is structured, compassionate, and always prioritizes your safety.

Please fill out the information below to help us determine which study may be the best fit for you. These questions are confidential.
Have you been feeling very down, sad, or hopeless for over the past 2 months?*

YesNo

Have you been feeling very nervous, anxious, or on edge over the past 2 months?*

YesNo

Are these feelings making it hard to function in daily life (work, school, relationships, or self-care)?*

YesNo

If yes, would you be willing to stop these medications with medical supervision, if required?*

YesNo

Have you tried at least two different antidepressant medications in the past without enough improvement? ?*

YesNo

Have you or an immediate family member ever been diagnosed with bipolar disorder, schizophrenia, or another psychotic condition?*

YesNo

Have you been diagnosed with any of the following mental health conditions?*

AnxietyEating disorderDepressionNonePosttraumatic stress disorder (PTSD)Other

In the past 6 months, were you diagnosed or treated for alcohol/substance use disorder?*

YesNo

How many times in your life have you used psychedelics including MDMA (ecstasy, molly), LSD (acid), psilocybin (mushrooms), DMT, ayahuasca or mescaline?*

When was the last time you used psychedelics including MDMA (ecstasy, molly), LSD (acid), psilocybin (mushrooms), DMT, ayahuasca or mescaline?*

Within the past 6 monthsWithin the past yearWithin the past 2 yearsMore than 2 years ago

If you are a daily user of marijuana, are you willing to discontinue use during the study?*

YesNoDoesn't apply to me

Are you willing to use contraception throughout the study and abstain from donating sperm or eggs?*

YesNo

Do you have any serious heart, brain, or other major medical conditions (heart attack, uncontrolled hypertension, stroke, seizures, cancer, kidney or liver disease)?*

YesNo

Thank you for your interest in psychedelic clinical research studies at TRIP Clinics. You may be eligible to participate. If you'd like to move forward, please select a 90-minute time frame during which you are most available to receive a brief call from our TRIP Clinic research coordinator.
Appointment: Clinical Trials

Life can be overwhelming. At TRIP Clinics, our licensed therapists provide compassionate, trauma-informed care to help you heal, build resilience, and reconnect with what matters most. All responses are HIPAA-protected.
Have you worked with a therapist before?

YesNo
Are you currently experiencing symptoms such as depression, anxiety, trauma, or relationship stress?

YesNo
Do you have thoughts of harming yourself or others?

YesNo
Would you prefer sessions at our Santa Monica or Hollywood location?

Santa MonicaHollywood
Please select a 90-minute time frame during which you are most available to receive a brief call from our TRIP Clinic coordinator.
Appointment: Therapy

Whether you’re starting treatment or managing ongoing symptoms, the right medication can help. At PSI TRIP Clinics, our psychiatric team offers careful, collaborative medication management rooted in science and your personal experience. All responses are kept HIPAA-protected
Are you currently taking psychiatric medication?

YesNo
If yes, please list psychiatric medication(s).
Have you ever had a difficult reaction to medication?

YesNo
If yes, please describe.
Are you currently under the care of a psychiatrist?

YesNo
Would you prefer sessions at our Santa Monica or Hollywood location?

Santa MonicaHollywood
Please select a 90-minute time frame during which you are most available to receive a brief call from our TRIP Clinic coordinator.
Appointment: Medication Management

Please select a 90-minute time frame during which you are most available to receive a brief call from our TRIP Clinic coordinator.
Appointment: Consultation

You are not alone. Help is available right now.

If you are having thoughts of harming yourself, please take one of these steps immediately:
In Los Angeles, you can call 988 (Suicide & Crisis Lifeline) available 24/7, free, and confidential.

For local support, you can also call the Didi Hirsch Suicide Prevention Center at (877) 727-4747 (24/7).

If you are in immediate danger, please call 911 or go to your nearest emergency room.

Thank you for your interest in TRIP Clinic.

You do not meet the criteria for our current trials but this doesn't mean psychedelic medicine isn’t right for you. We can add you to our list for future studies or you can explore options like Ketamine-Assisted Therapy (KAP) on our website.
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Confidential Screening Form