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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?
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Yes
No
Have you ever used other psychedelics (eg. LSD, Psilocybin, DMT, Ayahuasca, MDMA) before?
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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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