Ketamine Therapy Screening Form
Ketamine Therapy Screening Form
Mental health and medical screening for patients pursuing ketamine-assisted therapy for depression, PTSD, or chronic pain.
Patient Demographics
Full name *
Your answer
Date of birth
Mobile phone
Emergency contact name and phone
Your answer
Mental Health History
Primary diagnosis being treated
+ 16 more questions
About this template
Mental health and medical screening for patients pursuing ketamine-assisted therapy for depression, PTSD, or chronic pain.
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