Ketamine Quiz

1. What brings you here today?

I’m exploring new options for my mental health care (Depression, anxiety, PTSD)

My current treatment isn’t working as well as I’d like

I’m interested in learning more about ketamine therapy

I’m helping a loved one explore care options

I’m interested in learning more about other interventional psychiatry treatments: TMS, PRISM for anhedonia, PRISM for PTSD, VNS

2. Have you ever been diagnosed with any of the following:

Depression

Anxiety

PTSD

3. Have you tried any previous treatments or medications for mood or anxiety?

None so far

1–2 medications

3–4 medications

5 or more

4. What type of care are you currently receiving?

Psychiatry / Medication management

Therapy / Counseling

Both

None at this time

5. Ketamine therapy may not be right for everyone. Please tell us a little more about your medical history.

I am currently pregnant or may be pregnant

I have been diagnosed with schizophrenia or experienced psychotic symptoms

I have uncontrolled high blood pressure (hypertension)

I have untreated hyperthyroidism

I have a history of congestive heart failure, aneurysm, hemorrhagic stroke, or liver disease (cirrhosis)

I have a history of substance use

None of the above

6. What’s your current insurance provider?

Aetna

BCBS

Oscar

Cigna

UnitedHealthcare / Optum

Medicare

No Insurance

Others:

Provide other insurance provider here:

7. Full Name

8. Email address

9. Contact Number

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Thank you for completing our brief questionnaire.

Our care team will review your responses and contact you to discuss your next steps in exploring Ketamine-Assisted Treatment at Mindful Behavioral Health.

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