Intake form

Name *

Email address *

What is your primary concern or reason for seeking ketamine services?

Please select at least one option.

Depression

Anxiety

PTSD

Chronic pain

Have you previously received any form of mental health treatment?

If yes, please specify the type(s) of treatment you have received.

Are you currently taking any medications?

Please select at least one option.

Antidepressants

Anti-anxiety medications

Pain medications

None

Do you have any known allergies?

What is your preferred method of communication?

What days and times are you available for an appointment?

How did you hear about rejuvenate mind & body?

Which service or services are you interested in?

Please select at least one option.

In-home IV ketamine infusion

Nasal ketamine therapy (Physician-Supervised)

Combination therapy (IV + nasal ketamine)

Additional questions or comments

Rejuvenate Mind & Body