Intake Form

Interested in working together? Please complete our Intake Form and we will be in touch shortly. We can't wait to hear from you!

Name

First Name

Last Name

Current Age

Email

Phone

(###)

###

####

What services are you interested in?

Ketamine Assisted Psychotherapy (KAP)

Mindbody Therapy Sessions

Group Ketamine

Guided Ketamine Sessions

Student Therapist

Other

Please list the reasons for seeking MindBody Therapy / KAP / Guided Ketamine Sessions at this time:

How did you hear about us?

What is your experience with therapy? Please explain:

Please provide details on days of the weeks/times that will or won't work for appointments with us.

Which therapist would you like to work with? Leave blank if no preference.

The Therapists and Counselors practicing at Guide MindBody Therapy are independent providers who share and value the same principles for healing trauma. Individual Therapists and Counselors have separate policies, bill separately, and are NOT employees or agents of Guide MindBody Therapy.

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