(Draft 1) Pre-screening Questionnaire (1st Form)

Hello, and welcome!

We'd like to start with a short assessment to learn whether or not our ketamine-assisted therapy program is right for you. It's only a few short questions. After, you'll be able to schedule your first appointment on your therapy journey.

We can only treat clients that are 18 or over. What's your date of birth?*

MonthDayYear
Today's Date

MonthDayYear
Date
Age
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.

Our journeys are currently available for residents in New York and California. What state do you call home?
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 live in New York and California. We would love to stay in touch with updates on our services.

What are you seeking treatment for?

DepressionAnxietyStressTrauma / PTSDAddictionBipolar DisorderOther

Do any of the below circumstances apply to you?

I have a known allergy to ketamine.I am pregnant, nursing, or planning on getting pregnant.I have previously attempted suicide in my lifetime.I have a diagnosis of Schizophrenia, Schizo-affective disorder, and/or Bipolar I Disorder.I have been diagnosed with a substance use disorder or required rehabilitation.None of the above circumstances apply to me.

What's your name?

First NameLast Name
Email?*
example@example.com
Phone Number
Please enter a valid phone number.

I agree to Notice of Privacy Practices, Patient Privacy Policy, and Terms and Conditions

I acknowledge that I have read and understood the Notice of Privacy Practices and the Patient Privacy Policy.I acknowledge that I have read and understood the Terms and Conditions.
www.setsettinghealth.com/notice-of-privacy-practices
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