Ketamine Assisted Psychotherapy Intake Form

Please complete the following intake form for a free phone consultation with Gregg Brock, LMFT.

Access to online scheduling will be provided via email once form is submitted.

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Do you have any pre-existing medical conditions?(Required)

Are you currently taking any medications or supplements?(Required)

Have you had any adverse reactions to medications in the past?(Required)

Have you been diagnosed with any mental health disorders?(Required)

Have you received psychotherapy or psychiatric treatment in the past?(Required)

Do you have a history of suicidal thoughts or attempts?(Required)

Have you experienced any traumatic events or significant life stressors?(Required)

What are your primary reasons for seeking ketamine-assisted psychotherapy?(Required)

Can you describe your current symptoms and their severity?(Required)

Have you experienced any recent changes in mood or behavior?(Required)

Are you allergic to any medications, including ketamine?(Required)

Do you have any known sensitivities or adverse reactions to anesthetics or sedatives?(Required)

What specific goals do you hope to achieve through ketamine-assisted psychotherapy?(Required)

Are you open to ongoing psychotherapy sessions in conjunction with ketamine treatment?(Required)

Do you have a strong support system in place (family, friends, etc.)?(Required)

Are there any significant interpersonal conflicts or stressors in your life?(Required)

Do you currently use any recreational drugs or alcohol?(Required)

How frequently do you use these substances?(Required)

Have you ever received ketamine treatment before?(Required)

What are your expectations for the ketamine-assisted psychotherapy experience?(Required)

Are there any specific concerns or fears you have about the treatment?(Required)

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