What is the reason(s) you are seeking support? (Select all that apply)

Have you tried two or more psychiatric medications or types of therapy in the past that did not provide sufficient relief? *

Yes

No

Unsure

Are your current challenges significantly impacting your daily life, relationships, or work? *

Yes

No

Somewhat

Are you open to trying a different type of treatment for your mental health and well-being? *

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)? *

Yes

No

Unsure

How soon are you hoping to begin treatment? *

As soon as possible

Within the next 1-3 months

Just exploring options for now

What type of insurance do you have (if any)? *

Insurance coming soon. Please note, New Life Wellness does not currently accept insurance for ketamine treatments.

First Name *

Last Name *

Email *

Phone *

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