How did you hear of this agency/therapist? Who gave you our name to call, or why did you choose us?

Age

Gender Identity

Preferred Pronoun

Email

Name & Contact Information for Primary Therapist

Current Mental Health Diagnoses by Primary Therapist, Psychologist or Psychiatrist:

Please feel free to describe further:

Current list of all medications, including psychiatric medications, and dosages:

Name & Contact Information for prescribing physician or psychiatrist, if taking psychiatric medication(s):

Medication Allergies and Adverse Reactions

Name & Contact Information for Primary Physician:

Emergency Contact Name & Phone Number:

Relationship to Patient:

Name & Phone Number of support person who will be providing your transportation for each ketamine treatment:

Occupation:

Presenting Symptoms (can include physical, mental, emotional, relational, spiritual):

Is stress a major problem for you?

Do you experience significant mood issues?

Have you had panic or panic attacks?

Do you cry frequently?

Do you have problems with your eating or appetite?

Do you have any sleep concerns?

Have you been diagnosed with a psychotic or dissociative disorder?

Have you ever experienced mania or a mixed episode (mania and depression)?

For any questions above answered YES feel free to describe here

Please describe any of the areas you checked above here:

Have you ever previously attempted suicide?

Have you ever thought about hurting yourself or done so in any manner?

If yes, please describe past situations.

Please feel free to describe these situations further:

What things are going well for you currently in your life? In what areas are you thriving or doing fine?

What do you do for fun and recreation?

What and/or whom are your major supports?

Do you have a spiritual/religious path, and if so, what?

How do you nurture yourself?

Have you received ketamine treatment previously or participated in other psychedelic or altered consciousness experiences? What/Where/When

Please describe what went well in these experiences and any challenges you experienced during, or as a result, of this experience(s):

What would make ketamine treatment a success for you at this time?

What are you most hoping to accomplish with this support?

What concerns or questions do you have about ketamine treatment?

Please describe any particular needs or requests you have that would add to your comfort and care during a ketamine experience:

Anything I haven't asked about that is important for me to know about you?

Cancellation & Billing Policy

I understand that I am responsible for the full amount of my bill for services provided. • Unexpected events happen to all of us, and it’s understandable to forget an appointment or need to cancel at the last minute. However, to be fair to clients on the waitlist, I understand that there is a 24-hour cancellation policy which requires that I cancel my appointment at least 24 hours in advance. I understand that if I am unable to give at least 24 hour notice, there will be a $75 fee, and I may lose my regularly scheduled time slot or may be referred to another agency for services.

Consent to Treatment

I hereby consent to treatment by the staff of INNER PATH COUNSELING, LLC. I understand that INNER PATH COUNSELING, LLC uses an interdisciplinary approach to treatment and that the staffing about my case may include psychiatrists, nurse practitioners/primary care doctors, therapists, psychologists, and social workers, who may confer and consult regarding the best method of treatment. I understand that my treatment will be confidential except in cases of suspected harm to others, suspected physical or sexual abuse of minors or elders, or ordered by a court of law, or for insurance purposes. I understand that my clinician is required by law to report the above abuses. I will have the opportunity to discuss with my clinician the nature of my problem, the results of the initial evaluation, the treatment plan, alternative treatment, and reasonable foreseeable risks of treatment. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by INNER PATH COUNSELING, LLC. I am aware that I may stop my treatment at any time. The only thing I will still be responsible for is paying for the services I have already received. Please add your name here to accept the terms of INNER PATH COUNSELING, LLC Consent to Treatment

Limits of Confidentiality

INNER PATH COUNSELING, LLC recognizes that confidentiality is essential to effective therapy, and in order for therapy to work in the best way possible, you must feel safe about sharing your personal information with me. Under most circumstances, all information about you, in written or verbal form, obtained in the counseling process (including your identity as a client) will be kept ethically and legally confidential. Information will not be disclosed to any outside person(s) or agency without your written permission except in certain situations, which include, but are not limited to: • If you are determined to be an imminent danger of harming yourself or someone else • If you disclose abuse or neglect of children, the elderly or a disabled person(s.) • If you disclose sexual misconduct by a mental health professional • Your mental health conditions becomes a part of a lawsuit or other legal subpoena • If you authorized a release of information with your signature

Consent to Tele-Mental Health Informed Consent

I, hereby consent to participate in tele-mental health, as part of my psychotherapy. I understand that tele-mental health is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to tele-mental health: 1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. 2) I understand that there are risks, benefits, and consequences associated with tele-mental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-mental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/ emotional health as an issue in a legal proceeding). 5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-mental health services are not appropriate and a higher level of care is required. 6) I understand that during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at (505) 908-1953 to discuss since we may have to reschedule. 7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. 8) I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. © March 2020. National Association of Social Workers. All rights reserved. I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. How we use and disclose your protected health information with your consent: We will use the information we collect about you mainly to provide you with treatment, to arrange payment for our services, and for some other business activities that are called, in the law, health care operations. After you have read this notice we will ask you to sign a consent form to let us use and share your information in these ways. If you do not consent and sign this form, we cannot treat you. If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this. Disclosing your health information without your consent: There are some times when the laws require us to use or share your information. For example: 1. When there is a serious threat to your or another’s health and safety or to the public. We will only share information with persons who are able to help prevent or reduce the threat. 2. When we are required to do so by lawsuits and other legal or court proceedings. 3. If a law enforcement official requires us to do so. 4. For workers’ compensation and similar benefit programs. There are some other rare situations. Your rights regarding your health information: 1. You can ask us to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask us to call you at home, and not at work, to schedule or cancel an appointment. We will try our best to do as you ask. 2. You can ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends. 3. You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records, but we may charge you for it. 4. If you believe that the information in your records is incorrect or missing something important, you can ask us to make additions to your records to correct the situation. You have to make this request in writing. You must also tell us the reasons you want to make the changes. 5. You have the right to a copy of this notice. 6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our privacy officer and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. We will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please contact our privacy officer, who is and can be reached by phone at or by e-mail at 505.908.1953 or cara@innerpathcounseling.org

By signing this document I confirm that the information I have provided above is true and correct to the best of my knowledge.

Ketamine Treatment Form