Ketamine Treatment Suitability Quiz
What is the reason(s) you are seeking support? (Select all that apply)
Anxiety
Depression
PTSD / Trauma
Suicidal Ideation
Addiction
Chronic Pain
Postpartum
Lifestyle/Functional Medicine
Integration/Therapy
Other
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Have you tried two or more psychiatric medications or types of therapy in the past that did not provide sufficient relief?
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Yes
No
Unsure
Are your current challenges significantly impacting your daily life, relationships, or work?
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Yes
No
Somewhat
Are you open to trying a different type of treatment for your mental health and well-being?
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Yes
No
Unsure
If it meant you felt better, would you be willing to make personalized lifestyle changes (e.g., diet, exercise, sleep, stress management)?
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Yes
No
Unsure
How soon are you hoping to begin treatment?
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As soon as possible
Within the next 1-3 months
Just exploring options for now
What type of insurance do you have (if any)?
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Aetna
Anthem Blue Cross Blue Shield
UHC
Tricare
Medicare
Medicaid
Other Private Insurance
Self-Pay
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Insurance coming soon. Please note, New Life Wellness does not currently accept insurance for ketamine treatments.
First Name
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Last Name
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Email
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Phone
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