I am: *

over 18 years of age and seeking care for myself

a parent or guardian acting on behalf of a minor

a clinician seeking to collaborate/refer

Name of person completing this form *

First Name

Last Name

Phone

(###)

###

####

What are you reaching out about?

I’m interested in medication management and/or psychotherapy

I’m interested in Ketamine-Assisted Psychotherapy (KAP)

I’d like to schedule a one-time consultation

I’m a clinician looking to refer a client or collaborate

I'm interested in therapy intensives

Something else (please explain below)

Are you open to:

In-person sessions (Salem, MA)

Virtual sessions (telehealth)

Either / Both

Please select all that apply to you or your child:

Never taken psychiatric medication before

Taken meds in the past, but none currently

Currently taking meds prescribed by another provider

Never been in therapy before

Tried therapy in the past, but not currently

Currently seeing a therapist (or actively looking for one)