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.Format: 000-000-0000.
Email Address*
example@example.com
How did you hear about TRIP Clinics?*

BillboardBus AdFamily MemberFriendNewsletterProvider ReferralRadioSearch Engine (Google, Bing, etc.)Social Media (Facebook, Instagram, LinkedIn)

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

Clinical TrialsPsychotherapyKetamine-Assisted Psychotherapy (KAP)Psychedelic IntegrationMedication ManagementNot Sure

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

Santa MonicaHollywood

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

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

YesNo

Have you or an immediate family member (mother, father, brother, sister, child) 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

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 agoNever

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

Life can be complex but healing doesn’t have to be. At TRIP Clinic, our licensed therapists offer compassionate, trauma-informed support through psychotherapy, ketamine-assisted therapy, and integration sessions. All responses are confidential and HIPAA-protected.
Would you prefer sessions at our Santa Monica or Hollywood location?

Santa MonicaHollywood

Whether you’re starting treatment or managing ongoing symptoms, the right medication can help. At TRIP Clinic, our psychiatric team offers careful, collaborative medication management rooted in science and your personal experience. All responses are HIPAA-protected.
Would you prefer sessions at our Santa Monica or Hollywood location?

Santa MonicaHollywood