New Client Intake Form

Welcome to Be Well Ketamine Institute.

Thank you for considering Ketamine Infusion Therapy as part of your healing journey. This form helps our medical team understand your symptoms, medical history, and treatment goals so we can determine whether ketamine therapy may be appropriate for you.

Your responses are confidential and will only be used by our clinical team to evaluate your care and prepare for your consultation.

Please answer each question as accurately as possible.

Your Information

First Name *

Last Name *

Phone *

Email *

Date of birth *

Gender *

Male

Female

Address

Street Address

City

State

Country

Postal Code

Primary Concern

Current Symptoms

Rate the severity of the following (1–10): *

Depression
Anxiety
Stress
Sleep difficulties
Chronic pain
Emotional numbness

How long have you been experiencing these symptoms? *

Less than 6 months

6 months – 1 year

1–5 years

More than 5 years

Treatment History

Have you previously tried treatment for these symptoms? (Select all that apply) *

Have any treatments been effective? *

Medication History

Medical History

Goals for Treatment

What would you most like to improve in your life if treatment is successful? *

By checking this box, I consent to receive non-marketing text messages from Be Well Ketamine Institute regarding appointment reminders, treatment updates, and important information related to my care. Message frequency may vary. Message and data rates may apply. Text HELP for assistance. Reply STOP to opt out at any time.

I understand that this form does not guarantee treatment and that a medical evaluation is required to determine eligibility for ketamine therapy.

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