Our friendly and professional team is ready to begin your journey towards healing with this innovative treatment process. If you would like to enquire about an appointment, fill out the form below and we will contact you to go over the next steps. Questions? Call (737)471-4136

First Name *

Last Name *

Date of Birth *

Postal Code *

Email Address *

Phone *

May we use your contact information to text, email or leave voice mail to coordinate your care? *

Yes

How can we help you? *

I am interested in ketamine for the following: *

Depression

Anxiety

PTSD

Eating Disorder

OCD

Substance Use

Have you ever been hospitalized for a mental health condition? *

Please select

Yes
No
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Have you had any serious suicidal thoughts in the last 3 years? *

Please select

Yes
No
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If you answered "Yes" to the above, please provide details. If you answered "No" then put "N/A" *

What current medications are you taking? Please provide dosages if you can. *

Who referred you?

Staff

Anne Minor

Amy Lombardi

Crystal Suchyta

Erin Caldwell

Grace Gould

Kay Terrell

Lacie Hamilton

Morgan Grace

Timothy Stacey

Please note that Blossom does not provide behavioral health crisis services. If you are experiencing a crisis, please contact 911 for help.

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