KAP Client Screening Form (Pre-Intake)

Thank you for your interest in Ketamine-Assisted Psychotherapy (KAP). This brief form helps us get a sense of your background and current needs, and whether KAP might be a good fit for you. Your responses will remain confidential and are only used to support

your care.

All fields must be filled out in order to submit the form. If a question is not applicable then please fill in "N/A" .

Are you filling out this form for yourself or someone else? *

CLIENT INFORMATION

The primary email/phone number you provide is where you are going to receive all of our communication. Please submit an email/phone number that will be checked often.

Today’s Date *

Client's First Name *

Client's Last Name *

Client Preferred Name

Pronouns

Primary Email *

Primary Cell Phone *

By entering your phone number and email address, you agree to receive informational emails and/or SMS messages (waitlist updates, scheduling, appointment reminders, account notifications, therapy services, groups workshops or community events that could be helpful to you or your family) from us. Message frequency varies. Message and data rates may apply. Reply HELP or email us at [email protected] for assistance. You can opt out at any time by replying STOP. Our terms and conditions and messaging privacy policy are located on our Contact Page on our website.

* Providing your cell phone number will help us to better communicate with you regarding waitlist updates and services with us.

Date of birth *

Birth Sex *

Sexual Orientation *

Gender Identity *

What is your current employment status? *

Name of Current Therapist *

INSURANCE

The Artful Life can accept insurance for the intake session, preparatory sessions and integration sessions only. The medicine session is not billable to insurance and is private pay only (out-of-pocket).

The Artful Life can accept the major insurances listed below:

Aetna
Allways / MGH
Blue Cross Blue Shield
Blue Cross Blue Shield Medicare Advantage
Blue Benefit
Fallon
Harvard Pilgrim
Health Plans, Inc.
Mass General Brigham (MGB)
Mass General Brigham - ACO
Meritain Health
Tufts Commercial
Tufts Direct (Public)
Tufts Health Together (Public)
UMR
Unicare GIC
United Healthcare
Wellpoint
WellSense
Private Pay

We are NOT able to bill Medicare, Medicaid, Masshealth, Steward Health, Tricare, & Cigna

What is your Primary Insurance Provider? *

Insurance Plan Name *

Member ID *

We are best able to understand your plan if you upload a photo of the front and back of your insurance card. *

I understand that The Artful Life does NOT bill out-of-network insurances. *

Do you have a secondary insurance provider? *

If so, who is your secondary insurance provider?

I understand that The Artful Life is unable to bill your secondary insurance. If you have secondary insurance, you will be responsible for paying any copays or deductibles that are normally covered by secondary. We can provide a superbill at your request which you can submit to your secondary insurance for possible reimbursement. Please reach out to your insurance representative with any questions regarding reimbursement

1. Therapy History

Have you ever participated in psychotherapy, counseling, or other mental health services before? *

If yes, briefly describe the focus or goals of your therapy:

2. Current Mental Health Concerns

What are the main concerns or symptoms that bring you to consider KAP? (e.g., depression, anxiety, PTSD, grief, etc.) *

3. Mental Health Diagnosis

Have you ever been diagnosed with a mental health condition by a professional? *

If yes, please list any diagnoses (past or present):

4. Medication Use

Are you currently taking any psychiatric or other medications? *

If yes, please list the medications and dosages if known:

5. Psychedelic History

Have you ever used ketamine or any other psychedelic substances (e.g., psilocybin, LSD, MDMA, ayahuasca)? *

If yes, please share which ones and describe your experience, if comfortable:

6. Medical Conditions

Do you have any current or past medical conditions (e.g., heart conditions, high blood pressure, neurological issues) that we should be aware of? *

If yes, please list:

7. Substance Use

Do you currently use or have a history of substance use or misuse (including alcohol, cannabis, or prescription/illicit drugs)? *

If Yes, please explain.

8. Support System

Do you have a support person (family member, friend, etc.) who can assist you before and after your medicine sessions (e.g., transportation, check-ins)? *

9. Life Experiences & Emotional Safety

Are there any past experiences—stressful, painful, or overwhelming—that you feel might influence how you respond to altered states of consciousness or deep emotional work? *

If yes, is there anything you’d like to share that would help us better support your comfort and emotional safety during sessions?

10. Readiness & Intentions

Why are you interested in Ketamine-Assisted Psychotherapy at this time? *

What are you hoping to explore, heal, or gain from this experience? *

A few more things!

For waitlist check-ins and updates how would you prefer to be contacted? *

Would you like to be added to our newsletter? *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to The Artful Life therapists and/or office staff communicating with me via email or text message