Ketamine Therapy Intake Form
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Ketamine Therapy Intake Form
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The Ketamine Therapy Intake Form is purpose-built for ketamine infusion clinics, psychedelic-assisted therapy practices, and psychiatric offices offering ketamine as a treatment for depression, anxiety, PTSD, and chronic pain. As ketamine therapy grows in demand for treatment-resistant depression and other conditions that have not responded to traditional medications, clinics need a thorough intake process that goes beyond a standard psychiatric evaluation. This ketamine infusion patient form captures the detailed medical and psychiatric history required to determine candidacy, screen for contraindications, and establish a safe treatment protocol tailored to each patient.
The form includes comprehensive sections for psychiatric diagnosis history, previous treatment modalities and their outcomes, current psychotropic and non-psychotropic medications, substance use history, cardiovascular health screening, and specific contraindications such as uncontrolled hypertension, active psychosis, pregnancy, or known hypersensitivity to ketamine. Patients document their treatment goals -- whether targeting depression, anxiety, PTSD, suicidal ideation, or chronic pain -- and rate the severity of their current symptoms using standardized scales. The psychedelic therapy intake section also gathers information about prior experience with dissociative or psychedelic substances, current therapy and support systems, and the patient's understanding of what to expect during and after ketamine sessions.
Designed with both clinical safety and regulatory compliance in mind, this template includes a detailed informed consent agreement that explains the off-label nature of ketamine for psychiatric indications, expected effects and potential side effects, the requirement for a responsible adult to provide transportation after each session, and the clinic's monitoring protocols. Emergency contact information is collected upfront, and patients acknowledge their commitment to the recommended treatment series. Whether your clinic offers IV ketamine infusions, intramuscular injections, or sublingual ketamine, this intake form ensures that every patient is properly evaluated and documented before their first session.
What's included
- Complete psychiatric history and diagnosis documentation
- Medication list with dosage and prescribing provider
- Cardiovascular and contraindication safety screening
- Treatment goals and symptom severity assessment
- Emergency contact and transportation verification
- Informed consent with off-label use disclosure and e-signature
- Medical conditions checklist
Who uses this template
- Ketamine infusion clinics screening new patients for treatment eligibility
- Psychiatric practices offering ketamine for treatment-resistant depression
- Psychedelic-assisted therapy programs gathering comprehensive intake data
- Pain management clinics evaluating patients for ketamine-based chronic pain treatment
All form fields
16 fields across 3 pages. Customize any field after signing up.
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