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Name
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First
Last
Email
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Phone
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Age
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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?
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Do you have any medical conditions?
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Do you have a history of any major mental health diagnoses?
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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
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Do you take any medications or supplements?
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What about this program interests you?
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