Application for KAP Program

Application for KAP Program
Thank you for your interest in our KAP program. Please complete the form below. We do not accept Medicaid/Medicare. KAP can be beneficial for a variety of mental health diagnoses, particularly depression and PTSD. If you have any questions, feel free to contact us at kap@gladstonepsych.com or 443-708-5856.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Pronouns
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Preferred Location*
Insurance Carrier
Policy Holder
Applicant’s relationship to policy holder
Member ID or Policy #
YesNo
Mental Health Provider's Name
YesNo
Mental Health Provider's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Uncontrolled hypertensionBipolar disorder not controlled with a mood stabilizerBipolar disorder with current or recent maniaSchizophrenia, schizoaffective disorder, or severe personality disordersUncontrolled thyroid conditionActive substance use disorderHistory of intractable nauseaHigh risk of imminent suicideModerate to severe obstructive sleep apneaRespiratory issuesBrain tumorPast or Present Heart ConditionHistory of stroke or transient ischemic attackDissociative identity disorder or any other diagnosis where disassociation is severeRecent traumatic brain injuryPregnancyCurrently breastfeedingAllergy to ketamineHydrocephalusUnstable/poorly controlled cardiac diseaseDementing disorderSevere liver or kidney disorderGlaucomaUncontrolled seizure disorderUnder care of CardiologistOther medical conditions requiring ongoing care by a specialist or primary care physician’s office
Please provide information about any of the items you’ve checked
What is your primary interest in KAP? In other words, how do you hope KAP might help you in terms of shifts in mood and/or behavior?*
YesNo
YesNo
YesNo
Which days are you NOT able to take off work?
YesNo
The entire KAP series takes approximately 3 months to complete. KAP dosing sessions are 3 hours long. Other sessions are usually 60 minutes long. The sessions in the KAP series include:
- Three (3) screening appointments:
  - Advanced psychological assessment
  - KAP medical evaluation (Must be in-person)
  - KAP Therapy evaluation
- Three (3) KAP preparation sessions (one of these sessions must be in-person)
- Six (6) KAP dosing sessions (All of these must be in-person)
- Eight (8) KAP integration sessions
YesNo
PsychiatristPsychiatric Nurse PractitionerTherapist
Psychiatrist Name
Psychiatric Nurse Practitioner Name
Therapist Name
YesNo
By signing this application, I acknowledge and affirm that I have received and reviewed the KAP program documents, including all billing policies and procedures.

I understand the level of commitment required to participate in the program, and I reserve the right to withdraw my application at any time.

I understand that the submission of this application initiates the pre-screening process for determining eligibility to participate in the KAP program. Submission of this application does not constitute acceptance into the program and does not guarantee that I will be approved for participation. Final acceptance is contingent upon the completion of the full screening process and clinical review.
Signature*
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