Is this for you or a loved one?

Self

Loved One

If a loved one: are they aware?

Yes

No

(Please answer the following questions based on what you know about your loved one's situation.)

What brings you to Unchained Wellness today? *

I’m experiencing anxiety

I’m experiencing depression

I'm experiencing trauma/ptsd

A pain condition

Thanks for sharing!

After completing 2 sessions, over 70% of clients report improvement in trauma or pain related symptoms.

Thanks for sharing!

After completing 2 sessions, over 70% of clients report improvement in depression or anxiety related symptoms.

Ketamine is a medical breakthrough for treating depression. Are you familiar with Ketamine?

Yes

No

Are you currently prescribed medications for depression or anxiety?

Yes, for depression

Yes, for anxiety

Yes, for PTSD

Nope

Where can we send information about your personalized Unchained Wellness Program? *

Do any of the following apply to you?

Under 18 year old

Primary psychotic disorder (e.g. schizophrenia, psychosis)

Bipolar Disorder 1

Bipolar Disorder 2

Prepared for or attempted to end your life (in the past year)

Biological female who is pregnant, nursing, or trying to become pregnant

None of the above

We aren't fit for certain people or conditions. If you are in a life-threatening situation, call the National Suicide Prevention Line at +1-800-273-8255, call *988, or go to the nearest emergency room.

If you do qualify for Ketamine therapy, you will need a ride to and from our clinic. Can this be arranged? *

Yes

No

Our ketamine treatments are cash-pay only. Packages start at $395 per session. We do our best to make ketamine treatment as affordable as possible. Please indicate that you are open to discussing the affordability of our payment options.

I understand that the initial phone consultation is free, but the treatment itself is not, and am open to exploring affordable options.

First Name *

Last Name *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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