Field Trip Assessment

Welcome!

Let’s start with a brief assessment to learn if our ketamine-assisted therapy program is right for you. We will be able to book you into your first appointment after a few questions.

We are only able to treat those over the age of 18, can you please provide us with your birth date?*

Month Day Year
Thank you for taking the time to complete your self-assessment. Unfortunately, we cannot proceed at this time as we are only able to treat clients who are 18 years of age or older. We would love to stay in touch with updates on our services.
Email
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Your Personalized Journey

We offer ketamine-assisted psychotherapy treatments in our Health Centers and ketamine therapy through our At Home program. Regardless of where you are, our medical team will recommend a treatment program tailored to your unique, personal situation. We find that many clients coming through our program benefit from 4-6 ketamine exploration sessions combined with integration therapy over the course of 3-4 weeks.

What are you seeking treatment for?*

StressAnxiety (general worry, fear of social situations, sudden terror)Depressed (low mood, loss of interest in activities)Trauma or PTSD (post traumatic stress disorder)History of abuseEating disorderAddictionOther

How familiar are you with the benefits of ketamine-assisted therapy for mental health concerns?*

Not familiarSomewhat familiarVery familiarI have received ketamine treatment in the past

Over 90% of past Field Trip clients have reported an improvement in their anxiety and depression symptoms after completing our treatment program*. We hope to be able to help you as well.

*% of Field Trip clients with moderate to severe symptoms reporting improvements in symptoms after treatment who responded to Field Trip’s post-treatment questionnaire.

What is your goal in completing our treatment program? (Check all that apply)*

Gain relief from depressionAlleviate my anxietyGet off my medicationsPersonal growth and developmentGet a mental resetGain mental clarityGet a sense of personal empowermentFeel more connected with myself and others around meOther

Are you currently in mental health therapy?*

YesNo

Help us understand a little more about your medical history. Please check off any that apply.*

I have a known allergy to ketamineI am pregnant, or there is a possibility that I may be pregnantI have a personal history of schizophrenia or psychosisNone of the above apply to me
*Please note, there are some circumstances and conditions that would result in the decision that using ketamine is not the appropriate treatment for you. If you require immediate emergency assistance, either call '911', or if you live in the United States call the United States National Suicide Prevention Lifeline at 1-800-273-8255, or if you live in Canada call the Canada Suicide Prevention Service at 1-833-456-4566.

What’s your name? *

First Name Last Name
Your email?*
example@example.com
Your phone number?*
Please enter a valid phone number.
DOB

YearMonth Day
Date
DOB (text)
Your gender?*

WomanManNon-binaryPrefer Not to sayPrefer to self-describe:
I agree to Notice of Privacy Practices, Patient Privacy Policy, and Terms and Conditions:
*

By creating an account with Field Trip, I acknowledge that I have read and understood the applicable Notice of Privacy Practices and the Patient Privacy Policy and understand how my information will be collected and used by Field Trip. I also confirm that I will be in the same state as the Field Trip Health Centre location that I select.
*

I have also read and understood the relevant Terms and Conditions
Please note, responses to this digital screener tool will not be monitored. As a result, our teams are not available to handle emergency situations. If you require immediate emergency assistance, either call '911', or if you live in the United States call the United States National Suicide Prevention Lifeline at 1-800-273-8255, or if you live in Canada call the Canada Suicide Prevention Service at 1-833-456-4566.

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Next Steps

Click 'Complete' to see your next steps.
Coming Soon!

Our newest self-guided program mixes in-person and virtual sessions, giving you the flexibility you crave without any compromises on care. This one-year membership features Ketamine-assisted therapy and the ongoing support that you need to heal yourself.
Please provide your zip code and we will reach out when this new program launches.
Thank you for taking the time to complete your self-assessment. As our program is not recommended for clients who are pregnant or may be pregnant, we cannot proceed with your treatment at this time. We would love to stay in touch with updates on our services, in the event that you want to come back to us in the future.
Thank you for taking the time to complete your self-assessment. Based on your responses, the Field Trip program may not be the best fit for you at this time. However, things may change, and we welcome the opportunity to check in again in the future. We truly thank you for your interest in Field Trip and wish you health, happiness and healing.

If you're interested in future updates on our services, join our mailing list to keep in touch.
In Canada, the first step to get started with Field Trip Health is to book a FREE informational call with our care team. They will walk you through our process, including how to get an initial referral from your doctor or our Telehealth medical partner, and answer any of the questions that you have.

Once you’ve had your call with our care team and we’ve received a doctor’s referral, we will help you book a consult with our medical team to talk through your medical history and determine whether our treatment program is the right fit for you.

Click ‘Next’ to book your FREE informational call.
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Welcome!

Your Personalized Journey

Next Steps

Coming Soon!