Choose Ketamine Survey - Direct To Dashboard

1
Hi, what is your name?* This field is required.
First Name
Last Name
2
Nice to meet you {FirstName}, what's your email?* This field is required.
example@example.com
3
What are you interested in improving with the Choose Ketamine service?* This field is required.
Anxiety Levels
PTSD
Depression
Mood Disorders
Substance Abuse
Other
4
Choose Ketamine's clinician prescribed online ketamine therapy programs provide an effective alternative to traditional therapies and medications.

Ketamine assisted therapy is a breakthrough treatment helping individuals facing:

Chronic Stress

Anxiety

Depression

Post Traumatic Stress Disorder

Mood Disorders

Whether you feel stressed, lost, or anxious Choose Ketamine is here to help!
5
Lately, have you been struggling with any of the following?* This field is required.
Lack of motivation
Excessive worrying
Poor focus
Excessive negative self-talk
None of these
6

Thank you for sharing!

After completing our program, over 90% of our clients report an improvement.

We are so confident that if you are not 100% satisfied at any stage of the process we will refund you the full cost of the program.

Dr. Stephanie Coleman, MD. & Choose Ketamine Medical Advisor
7
Are you located in Colorado, Nevada, Washington State, New Mexico, Iowa or Minnesota?* This field is required.
Yes
No
8
Do any of the following apply to you?* This field is required.Choose Ketamine isn't a fit for certain people or conditions. If you are in a life-threatening situation, call the National Suicide Prevention Line at +1-800-273-8255, call 911, or go to the nearest emergency room. Responses are not monitored in real-time by Choose Ketamine.
Under 18 years old
Biological female who is pregnant, nursing, or trying to become pregnant
Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder)
Family history of psychotic disorder (e.g. schizophrenia, etc)
Prepared for or attempted to end your life (in the past year)
Method, intent, or plan to commit suicide (in the past month)
Diagnosed with a personality disorder (e.g. bi-polar etc)
None of the above apply to me
9
How much do you think the average ketamine treatment costs?* This field is required.
$500
$1000
$2000
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Other ketamine sessions can vary in cost from $500 - $2,000 per session, and most ketamine clinics do not provide integration programs alongside treatment.

Choose Ketamine's clients pay a $50 refundable deposit to visit the clinician. Once fully approved for this treatment by the clinician, the balance of $173 per Choose Ketamine treatment (two treatments) is paid. The $50 deposit will be refunded if there is a decision not to proceed with the treatment.

And, the even better news is that we accept Health Savings Account (HSA) payments.
11
Your journey is supported by our certified guides who are trained in psychedelic support including preparation and integration. Do you prefer your guide to be...* This field is required.
Spiritual
Clinical
Analytical
I'm not sure
12
What is your preferred contact method?* This field is required.
Email
Text Message
Phone Call
13
What is your phone number?
Please enter a valid phone number.
14
Do you have any questions for us?
Huge
Large
Normal
Small
Ok
Ok
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