Intake Questionnaire

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– Step 1 of 2

Do you have a diagnosis of schizophrenia or any other psychotic disorder? *

Have you experienced any recent episodes of psychosis within the last six months? *

Do you have an active seizure disorder that is not well-controlled by medication? *

Do you have a history of kidney and/or bladder disease? *

Is your blood pressure currently uncontrolled or consistently high, even with medication? *

Are you currently using opioids or other narcotic medications for pain management? *

Are you pregnant or planning to become pregnant soon? *

Are you able to pay for ketamine treatment without insurance coverage? *

If no, further discussion about financial options may be necessary.

Do you have family or friend support? *

Are you currently under the care of a psychiatrist or mental health professional? *

Please contact us to discuss alternative treatments that we can offer at West Eastern Health

Final determination will be made after an evaluation by our medical team

Name *

Phone *

Email *