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Is Ketamine Right for You?

Our Ketamine Screening form is the first step in determining if Ketamine Therapy may be a suitable treatment option for you. The screening form consists of a brief questionnaire designed to help us understand your medical history, current symptoms, and treatment goals.

Once you submit the screening form, our team of experienced professionals will carefully review your responses to determine if Ketamine Therapy may be a suitable treatment option for you. We may contact you via phone, email, or text message to follow up on your screening form and provide you with information regarding our services.

Ketamine Screening

Please fill out the following form
to the best of your knowledge.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
Have you been diagnosed with any of the followng:
Are you currently taking prescribed medictions?
Have you done Ketamine Therapy in the past?
Have you experienced any of the following?
Are you Pregnant?
Negative reaction to anesthesia in the past?
Do you currently have a Therapist?
Are you a current patient at Alevea?
Would you like us to contact you?

Thanks for submitting! A staff member will review your submission and, with your permission, will contact you with any further details or questions. 

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