Home
Projects
Events
Music
Contact
My Story
Gallery
Menu
Home
Projects
Events
Music
Contact
My Story
Gallery
Contact
Get In Touch With Me
1575 Evergreen Ave, Juneau, Alaska 99801, USA
(907) 586-8164
info@serenamalkani.com
Your Name
Your Number
Your Email
Message
Send Email
Get In Touch With Me
Your Name
Your Number
Your Email
Message
Send Email
Shopping Basket
Apply Now
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Age
(Required)
Have you ever used ketamine before?
(Required)
Yes
No
Have you ever used other psychedelics (eg. LSD, Psilocybin, DMT, Ayahuasca, MDMA) before?
(Required)
Yes
No
Which other psychedelics have you tried before?
(Required)
Do you have any medical conditions?
(Required)
Do you have a history of any major mental health diagnoses?
(Required)
Major Depressive Disorder
Generalized Anxiety Disorder
Bipolar Disorder
Schizophrenia or Schizoaffective Disorder
Episode of psychosis
Other
If you selected other in the previous question, please specify here
(Required)
Do you take any medications or supplements?
(Required)
What about this program interests you?
(Required)
×
