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 #
Do you currently have a mental health provider?
Mental Health Provider's Name
Do we have permission to contact your mental health provider to discuss your potential participation in KAP?
Mental Health Provider's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please check any of the following conditions that apply to you.

Other 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?
Do you have access to a support person or persons? For instance, trusted friends or family who could provide support for you as you proceed through the KAP process?
Do you have the ability to take off work for a minimum of 1 day/week for 6 consecutive weeks?
Are there specific days of the week that you are NOT able to take off work?
Which days are you NOT able to take off work?
You will NOT be able to drive on the 6 ketamine dosing days. Are you able to secure transportation to and from Gladstone on those days?
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
Are you able to commit to the entire series as outlined above?
Are you currently in treatment with a psychiatrist, psychiatric nurses practitioner, and/or therapist?
Psychiatrist Name
Psychiatric Nurse Practitioner Name
Therapist Name
I further acknowledge that participation in the KAP program involves an additional out-of-pocket program fee of $1500. This fee is separate from and in addition to any applicable copayments, coinsurance, or deductible amounts as determined by my insurance plan. These insurance-related costs will remain my financial responsibility. Payment plans are available.
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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