Ketamine Assisted Psychotherapy Questionnaire

Thank you for your interest in KAP!

Please answer the following questions so we can prepare for a consultation call to see if it might be a good fit for you.

Once you submit the form, you will be automatically emailed a short video about KAP along with a few articles to read. If you don't see it right away, please check your Spam folder. It will be helpful if you can look over these materials before the consultation call.

First Name *

Last Name *

Phone *

Email *

How did you learn about ketamine and KAP? *

How did you learn about our clinic? *

Are you able to attend in person sessions in Campbell? *

Yes

What problems or struggles are you hoping to work through with KAP? *

Are you currently seeing a therapist regularly? *

Yes

Are you taking any psychiatric medications, and if so which ones? *

Have you ever received a diagnosis of bipolar disorder, dissociative disorder or psychosis? *

Do you have any health concerns, specifically regarding high blood pressure, heart, liver or bladder issues? *

Do you now, or have you in the past, struggled with substance or addiction? *

Are you currently pregnant or breastfeeding? *

Yes

Have you ever had experiences of non-ordinary or altered states of consciousness (including ketamine but also including other medicines or breath work)? How was the experience for you? *

KAP sessions are 3 hours long and you cannot drive yourself home. Please indicate the days that you may be able to do a KAP session. Please note the more options we have the sooner we can schedule you. (check all that apply) Saturday openings are in limited supply and high demand. If that is the only day you are available then there is likely to be a wait. *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What questions do you have about KAP or about our clinic?

Fees associated with Ketamine Assisted Psychotherapy

KAP is an investment in your self and your mental health. It is not cheap, but can offer long term benefits that you may not be able to access in other ways.

OPTION A: Lozenge sessions with a Therapist:

Psychological Intake, 90 min, one time fee of $300
Medical Intake, 60 min, one time fee of $500
Preparation and Integration sessions, as needed, $185-250 each (depending on provider)
3 Hour KAP medicine session, $650-$850 each (depending on provider; assume 4-6 sessions will be needed)

OPTION B: IM (intramuscular injection) sessions with a Psychiatrist:

Intake, 90 min, one time fee of $650
Preparation and Integration sessions, as needed, $450 each
3 Hour KAP medicine session, $1350 each (assume 4-6 sessions will be needed)

We are trying to increase accessibility by offering monthly KAP Booster Groups at half the cost of individual KAP sessions, but you must attend an initial series of individual KAP sessions first to make sure that you are a good candidate for group work.

You may apply for a rate reduction by completing the questions in the next section.

This section is optional.

What is your annual Household Income?

Are there other people you are financially supporting? Please describe.

What other sources of financial support do you have?

Do you have out of network insurance benefits? Please describe.

What is your total budget for KAP services?

Are there any extenuating circumstances we should consider? Please describe.

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