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Start Your Assessment

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Do I Qualify?

Email *

Phone *

First Name *

Last Name *

Check diagnoses (currently have or have had) check all that apply *

Major Depressive Disorder

PTSD

Bipolar Disorder

Anxiety or Panic Attack Disorder

Autism Spectrum Disorder

Schizophrenia

Schizophrenia Disorder

Please describe any medical issues check above (N/A) if none *

Psychiatric Hospitalizations (List Hospital Name, Dates, Length of Stay, Reason) *

Are you currently taking medication(s) or have you ever been prescribed medication(s) for: *

Depression
Anxiety
Both
Neither
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Please check and describe any medical issues

Thyroid concerns

Cardiovascular Concern

Stroke

Heart Attack

High Blood Pressure

Please describe any medical issues check above

Why are you interested in Ketamine Therapy? *

What would you like to gain from Ketamine Therapy Sessions? *

Have you ever suffered from substance dependence or abuse? *

Yes

Substance Abuse History: Please check all that apply (Past, Current) *

THC

IV Drug Use

Opiates

Benzodiazepines

Stimulants

Cocaine

Alcohol

Tobacco

Steps to Receive Treatment

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Testimonials

My experience was Kiaya was fantastic. I appreciate that they embrace cutting edge treatments, and their holistic approach. Love it!

The team at Kiaya Wellness helped transform my direction in life with renewed energy.

Thank you Jennifer and team for your patience and support in helping me achieve my transformations!

If you, or someone you know, is in crisis or needs immediate assistance, please call 911 Send Textimmediately. To talk to someone now, please call the National Suicide Prevention Lifeline at 1-800-273-8255 Send Text.