Clone of CMAT Suitability Questionnaire

1
Which group are you interested in?* This field is required.Our men's and women's groups are open and affirming. If you feel called to a particular group's healing space, you are welcome there — regardless of the gender you were assigned at birth. Please indicate which group you are interested in below.
Men's Group
Women's Group
2
Your Full Name* This field is required.
First Name
Last Name
3
Your Email* This field is required.
example@example.com
4
Your Phone Number* This field is required.
Area Code
Phone Number
5
Please verify you are a human* This field is required.
6
How did you hear about CMAT?* This field is required.
Please Select
Please Select
My healthcare providers (eg. Therapist, Primary Care Provider, Social Worker, etc)
Coach
Google
Social Media
Word of mouth/friend
Other
7
Do you meet the following eligibility criteria?* This field is required.You must meet ALL of the following criteria in order to access our Ketamine Assisted Group Therapy services. I am a resident of Canada I am an adult aged 18 years or older I am interested in applying for Ketamine Assisted Therapy for myself
YESNO
8
Are you aware that individuals with the following health conditions are not eligible for Ketamine Assisted Therapies?* This field is required.Untreated high blood pressure Unstable cardiovascular disease (e.g. recent or untreated heart attack or stroke) Uncontrolled thyroid disorder Pregnancy Active/unstable seizure disorder Advanced/severe liver or kidney disease Acute angle glaucoma
YESNO
9
I understand that Group Ketamine Assisted Therapy is private pay and I have the means to participate.Treatment is not covered under provincial healthcare plans. Payment options include: 12 monthly instalments of ~$196 CMAT is pleased to offer interest free financing terms at 0% - LEARN MORE HERE $2,350 Payment 17 treatment hours @ $138/treatment hour *Limited third party private insurance may be applicable to some of the treatment costs.
YESNO
10
If you interested in being contacted if there are changes to our costs, suitability or services, please mark yes below
YESNO
11
I attest the information I have provided is true, accurate and complete to the best of my knowledge.
YESNO
12
Optional: Is there anything else you would like to share with our team?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: