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Psychotherapy Services
Ketamine-Assisted Psychotherapy
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Patient Forms
About
Work With Me
Psychotherapy Services
Ketamine-Assisted Psychotherapy
Licensed psychotherapist helping you on your journey toward self healing and heightened awareness
Fees & Payments
Contact
Free Consultation
Contact
Patient Forms
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Patient
information
forms
Please fill out the Patient Information below.
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Is it ok to text you?
*
Yes
No
Sex
*
Male
Female
Other
SSN
*
Martial Status
*
Single
Married
Widowed
Separated
Divorced
Email
*
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
(###)
###
####
Primary Insurance Information
Insurance Company Name
*
Insurance ID
*
Group #
*
Insurance Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Phone
*
(###)
###
####
Copayment
*
Yes
No
If yes, how much?
$
Are you the Primary Subscriber or Dependent?
*
Subscriber
Dependent
If you are not the Subscriber, please share the Subscriber's Name and their relationship to patient.
Thank you!
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