KETAMINE ASSISTED PSYCHOTHERAPY FORMS
Paperwork! It's a part of our world.
I am providing our essential information documents and consent forms here, so that you may begin the process of referral to our services. These steps are required before beginning treatment.
I am providing our essential information documents and consent forms here, so that you may begin the process of referral to our services. These steps are required before beginning treatment.
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To initiate referral to our services, you will need to have your mental health provider complete our KAP Referral Form:
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Please have your provider email this as a password-protected document to [email protected].
Receipt of this form is required before your initial preparation session.
Receipt of this form is required before your initial preparation session.
Treatment with ketamine is a specialty service, and it is very important to us that you are fully informed about our procedures and the risks/benefits involved. Please set aside some time to absorb this information, and make note of any questions or concerns you have while reading this form so that we may discuss them when we meet.
1) READ these three information documents:
1) READ these three information documents:
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KETAMINE ASSISTED PSYCHOTHERAPY INFORMATION: This document provides essential information about our KAP procedures, as well as about ketamine itself.
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KAP PRACTICE POLICIES: This document explains our policies regarding confidentiality, payment of fees, cancellations, professional medical records, and complaints.
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KAP PREPARATION AND AFTERCARE GUIDE: These physical and psychological instructions will help optimize your experience and minimize ketamine's potential adverse side effects as much as possible.
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KAP INTEGRATION TIPS: We offer a collection of suggestions to assist you in applying insights gained during your journey into your life.
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2) PRINT and SIGN these three consent documents (you may request that I print copies for our initial session):
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KAP INFORMED CONSENT: This document, when signed, indicates that you understand and consent to the information stated in BOTH the KAP Information and KAP Practice Policies forms. Signature required.
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HIPAA INFORMATION AND CONSENT FORM: We are required by law to provide you with this information so you may understand your rights and protections related to the use and disclosure of your identifiable health care information. Signature required.
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KAP EXCHANGE OF INFORMATION: This authorizes a mutual exchange of information with your mental health provider, which is required to ensure coordinated care in a collaborative treatment plan. Signature and provider information required.
3) Bring these signed documents to your initial preparation session (or read and sign them if I have printed them for you). I will review them when you arrive to make sure they are complete, and will be sure to check whether you have any questions or concerns about the material. I am happy to provide you with copies of anything you have signed.
4) I will also enter you into our electronic health record system, which will invite you to our patient portal, and allow you to enter your personal information digitally on a secure platform. Please complete this before our initial session.
We will assess and determine together if KAP is the best intervention for you during our initial meeting. If we collaboratively decide to move forward, I will book you a medical screening appointment with my physician partner.
We will also initiate our digital mental health surveys and screening tools, which will allow us to track your progress and responsiveness to ketamine treatment. These should be completed before our second preparatory session.
Please let me know if you have questions or concerns about any of these procedures!
We will also initiate our digital mental health surveys and screening tools, which will allow us to track your progress and responsiveness to ketamine treatment. These should be completed before our second preparatory session.
Please let me know if you have questions or concerns about any of these procedures!
Photo used under Creative Commons from ell brown.