Sana Healing Collective Services Inquiry Form
Are you interested in receiving services at Sana Healing Collective?Please complete this inquiry form, and a member of our team will follow up with you soon.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Which of our services are you interested in receiving? (Check all that apply)
*
Group psychedelic integration
Group ketamine-assisted therapy
Individual therapy
Individual ketamine-assisted therapy
Psychedelic Integration
Art therapy
Somatic therapy
Meditation-based therapy
Spirit Lab
How did you hear about us?
*
Please let us know how you found out about Sana. If you were referred by a therapist or other provider, please note their name.
OPTIONAL: Please briefly explain why you are seeking services from Sana Healing Collective at this time.
Do you currently have a primary therapist?
*
If so, please share their name
Do you wish to use your health insurance to pay for services? If so, who is your insurance provider?
*
Please specify if it is an HMO or PPO plan
Do you have a preference with which provider you will work?
Please Select
Geoff Bathje
Vilmarie Fraguada Narloch
Valery Shuman
Eric Majeski
Jean Edrada (for Spirit Lab only)
No preference
If you have a preference for a therapist please let us know. While we will do our best to ensure you get paired with your preferred therapist, availability and other factors may impact which therapist(s) are available to work with you.
Please verify that you are human
*
Submit
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