KAP Smart Screening

About You Your Goals Health Background Wellness History Current Care Your Preferences

Let me know a little about you so I can follow up personally.

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Preferred Contact Method *

Understanding what you are currently taking helps me ensure your safety and comfort.

Are you currently taking any medications? *

Yes No

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

Which treatment pathway interests you? *

Sublingual KAP Lozenge-based, 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?

Your information is encrypted and confidential.