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What is prompting you to explore this type of care at this time in your life and/or what do you see as your current obstacles or struggles? What areas are you looking to explore?

If yes to any of the above, are you currently receiving medical treatment? Please use this space to also further describe medical conditions selected above. For example, how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc.

Please list all medications and supplements you are currently taking?

Do you have any experience with dissociative trauma?

Are you currently experiencing any of the following: active mania, active suicidality, active psychosis?

Do you have a current psychiatrist and/or therapist?

History of spiritual exploration and/or psychotherapy, counseling? How do you feel about it and what was the most helpful. You're welcome to include any psychedelic exploration and how you felt about it here as well:

How did you hear about me?

Ketamine Assisted Therapy - Questionnaire

Marlee Dent, LPC