Free KAP Screening

Take the first step toward healing. This brief questionnaire helps us determine if Ketamine-Assisted Psychotherapy may be right for you.

100% Free • No Obligation • Confidential

Before We Begin

Your safety is my highest priority. This screening helps me understand your background and determine whether KAP is a safe and appropriate option for you. There are certain medical and mental health conditions that may disqualify someone from this treatment, and it is important we identify those early.

Please answer honestly. All information is confidential and protected under HIPAA. This is not a commitment to treatment — it is simply the first step in exploring whether KAP could help you. I will personally review your responses and reach out within 1-2 business days.

Your Contact Information

So I can reach out to you after reviewing your screening.

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Preferred Contact Method *

What Brings You Here

Help me understand what you are hoping to address.

What are you seeking help with? *

Select all that apply.

Depression
Anxiety
PTSD
Complex PTSD
Trauma (general)
Phobias (e.g., fear of flying)
Grief or Loss
Chronic Pain
OCD
Substance Use
Self-Criticism / Shame
Relationship / Attachment Issues

Other concerns or anything you would like me to know:

Have you tried therapy before? *

Yes
No

Are you currently in therapy?

Yes
No

Are you a veteran, first responder, or work in a high-stress profession?

Yes
No

Medical History

Certain medical conditions may affect your eligibility for KAP. Please answer as accurately as possible.

Do you have any of the following conditions? *

Select all that apply. These may affect eligibility.

Uncontrolled High Blood Pressure
Heart Disease or Heart Conditions
History of Stroke
Liver Disease
Kidney Disease
Seizure Disorder / Epilepsy
Glaucoma
Thyroid Disorder
Diabetes
None of the Above

Some of the conditions you selected may require additional medical clearance. This does not necessarily disqualify you, but we will need to discuss this further and may require a note from your physician.

Are you currently pregnant or planning to become pregnant?

Yes
No
N/A

Do you have any allergies to medications? *

Yes
No

Please list your medication allergies:

Mental Health History

This helps me understand your mental health background and ensure your safety.

Have you ever been diagnosed with any of the following? *

Select all that apply.

Major Depression
Bipolar Disorder
PTSD
Complex PTSD
Generalized Anxiety
Panic Disorder
OCD
Schizophrenia
Schizoaffective Disorder
History of Psychotic Episodes
Personality Disorder
None of the Above

Important: Some of the conditions you selected (such as schizophrenia, schizoaffective disorder, or history of psychosis) are generally considered contraindications for ketamine therapy. I will review this carefully and discuss it with you during our consultation.

Are you currently experiencing suicidal thoughts? *

Yes
No

Have you ever been hospitalized for a mental health crisis?

Yes
No

Please briefly describe:

Do you have a history of substance abuse or addiction? *

Yes, currently active
Yes, in recovery
No

Please describe (substance, duration, recovery status):

Current Medications

Some medications may interact with ketamine. Please list everything you are currently taking.

Are you currently taking any medications? *

Yes
No

Please list all current medications, dosages, and what they are for:

Are you taking any of the following? (may interact with ketamine)

Select all that apply.

Benzodiazepines (Xanax, Klonopin, Ativan)
MAOIs
Lamotrigine (Lamictal)
Stimulants (Adderall, Ritalin)
Opioids
None of these

Your Interest in KAP

Help me understand what you are looking for so I can best support you.

Which treatment pathway interests you? *

Sublingual KAP (lozenge, in my office, 3-hour session)
IV Ketamine + Therapy (in a medical office, 2-hour session)
Not sure yet — I would like to discuss both options

Do you already have a medical provider who can prescribe ketamine?

Yes
No, I will need a referral

How did you hear about KAP or Life Solutions?

Is there anything else you would like me to know?

Important Information

By submitting this form, you understand that this is a preliminary screening only and does not constitute a medical evaluation or guarantee of treatment. A full clinical assessment will be conducted during your intake session. All information provided is confidential and protected under HIPAA. Heleen Woest, LPC, will personally review your responses and contact you within 1-2 business days to discuss next steps.

I confirm that the information I have provided is accurate to the best of my knowledge, and I consent to being contacted by Life Solutions Counseling regarding Ketamine-Assisted Psychotherapy. *

Your information is encrypted and confidential.

Thank You!

Your screening questionnaire has been submitted successfully. I will personally review your responses and reach out to you within 1-2 business days.

If you have any urgent questions in the meantime, please contact me at lifesolutions.io/contact.

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KAP Free Screening

Free KAP Screening

Before We Begin

Your Contact Information

What Brings You Here

Medical History

Mental Health History

Current Medications

Your Interest in KAP

Important Information

Thank You!

Something Went Wrong

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