Synaptic Care Access & Scholarship Application
Apply for financial assistance for ketamine-assisted psychotherapy at Synaptic Institute. Please complete all relevant sections to help us assess your eligibility.
SECTION 1: Personal Information
Tell us about yourself so we can better understand your needs.
Full Name
*
First Name
Last Name
Pronouns (optional)
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Select your preferred communication methods
Email
Phone
Text Message
Are you currently a client at Synaptic Institute?
*
Yes
No
If no, are you open to establishing care here?
*
Yes
No
SECTION 2: Financial Information
Provide details about your financial situation to help us assess your eligibility.
Employment Status
*
Full-time
Part-time
Unemployed
Student
On disability
Other
Household Income Range (Please select a bracket)
*
Under $20,000
$20,000 to $35,000
$35,000 to $50,000
$50,000 to $75,000
$75,000 to $100,000
Over $100,000
Number of individuals supported by this income
*
Insurance Status
*
Uninsured
Underinsured
Insured, please list your plan
Do you currently receive any social services such as disability, Medicaid, or food stamps?
Disability
Medicaid
Food Stamps/SNAP
None
Other
Please describe your current financial situation and the reasons that paying the full cost for KAP would be a barrier for you.
*
SECTION 3: Clinical Context
Tell us about your current mental health care and treatment history.
Are you currently in therapy or psychiatric care?
*
Yes
No
If yes, with whom?
*
Have you discussed ketamine-assisted therapy with a provider before?
*
Yes
No
Have you previously received ketamine treatment, including infusion, lozenge, or IM administration?
*
No
Yes
Yes, please describe your previous ketamine treatment.
*
What brings you to consider ketamine-assisted psychotherapy at this time?
*
What other treatments or approaches have you tried, and what was or was not helpful?
*
SECTION 4: Identity and Intersectionality (Optional)
Synaptic Institute is committed to increasing access to care for historically marginalized communities. You may share any identities or experiences that feel important, such as race, gender identity, sexual orientation, disability, cultural community, or experiences of systemic barriers. This section is optional.
Identities or experiences you'd like to share (optional)
SECTION 5: Logistics and Commitment
Let us know about your ability to attend sessions and any scheduling considerations.
Do you have reliable transportation to attend appointments?
*
Yes
No
If no, please describe any challenges.
*
Are you able to commit to attending preparation sessions, medicine sessions, and integration sessions as scheduled?
*
Yes
No
Do you have any scheduling limitations we should be aware of?
SECTION 6: Agreement & Submission
Please review the terms and provide your agreement below.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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