Skip to content
Get Started Today
COVID-19 Help Center
Financing Options Available
Monday – Friday 9 AM – 6 PM
Need to Refer a Patient?
Search:
SEARCH
Ketamine Wellness Centers
Ketamine Treatments Phoenix, Arizona
Locations in AZ, CO, IL, MN, TX, WA, FL
855-KET-WELL
Subscribe to the KWC Newsletter
Home
About
Core Values
Why KWC?
Meet The Team
How To Get Started
Cost, Financing, & Insurance
Patient Testimonials
FAQ / Frequently Asked Questions
Treatments
Depression
Neuropathic Pain & Chronic Pain
Post-Traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
Suicidality
Insurance
Locations
Phoenix-Mesa, Arizona
Tucson, Arizona
Denver, Colorado
Seattle, Washington
Dallas-Fort Worth, Texas
Houston, Texas
Chicago, Illinois
Minneapolis–St Paul, Minnesota
Jacksonville, Florida
Patient Support
Facilitated Treatment Support
Meetups & Education
KetWell Therapy Products
Nutraceutical Supplements
KetWell Inspiration Partner Program
Facebook Patient Support Group
Patient Referral Program
Hero Discount
Travel Discounts
Blog
KWC Podcast
All Podcasts
A Closer Look at Spravato (Esketamine)
Fact or Fiction?
Ketamine Success & Insights
Healthy Living & Mental Health
Press, Media, Company Announcements
“A Hero’s Journey: Mallory’s Story”
Forms
I. Intake Form: Patient Intake
II. Intake Form: Ketamine Information Package
III. Intake Form: Depression Index
Medical Records Release & Request
Authorization for Communication
Make a Payment
Patient Referral Program, Earn $100!
Refer Your Patient To Us
Contact Us
Home
About
Core Values
Why KWC?
Meet The Team
How To Get Started
Cost, Financing, & Insurance
Patient Testimonials
FAQ / Frequently Asked Questions
Treatments
Depression
Neuropathic Pain & Chronic Pain
Post-Traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
Suicidality
Insurance
Locations
Phoenix-Mesa, Arizona
Tucson, Arizona
Denver, Colorado
Seattle, Washington
Dallas-Fort Worth, Texas
Houston, Texas
Chicago, Illinois
Minneapolis–St Paul, Minnesota
Jacksonville, Florida
Patient Support
Facilitated Treatment Support
Meetups & Education
KetWell Therapy Products
Nutraceutical Supplements
KetWell Inspiration Partner Program
Facebook Patient Support Group
Patient Referral Program
Hero Discount
Travel Discounts
Blog
KWC Podcast
All Podcasts
A Closer Look at Spravato (Esketamine)
Fact or Fiction?
Ketamine Success & Insights
Healthy Living & Mental Health
Press, Media, Company Announcements
“A Hero’s Journey: Mallory’s Story”
Forms
I. Intake Form: Patient Intake
II. Intake Form: Ketamine Information Package
III. Intake Form: Depression Index
Medical Records Release & Request
Authorization for Communication
Make a Payment
Patient Referral Program, Earn $100!
Refer Your Patient To Us
Contact Us
Depression Index
If you have any questions about this form, our staff is available during regular business hours (Mon - Fri, 9am - 6pm) to assist. Call us at 855-KET-WELL.
Name
*
First
Last
Email
*
Phone
*
Patient Data
I feel tired, despite sleeping 8-10 hours.
*
Most of the Time
Some of the time
Rarely
Never
I have had a significant change in appetite or interest in food.
*
Most of the Time
Some of the time
Rarely
Never
I prefer to be alone.
*
Most of the Time
Some of the time
Rarely
Never
I avoid being around friends or family.
*
Most of the Time
Some of the time
Rarely
Never
I avoid activities that are positive to my health such as eating healthy, exercising, or attending routine doctor visits.
*
Most of the Time
Some of the time
Rarely
Never
I have trouble sleeping.
*
Most of the Time
Some of the time
Rarely
Never
I think about ending my life.
*
Most of the Time
Some of the time
Rarely
Never
I feel my family and friends would be better off without me.
*
Most of the Time
Some of the time
Rarely
Never
I feel there is nothing to look forward to in my future.
*
Most of the Time
Some of the time
Rarely
Never
I have feelings of guilt or shame.
*
Most of the Time
Some of the time
Rarely
Never
I drink or use drugs to excess.
*
Most of the Time
Some of the time
Rarely
Never
I have stopped participating in activities or attending my house of worship
*
Most of the Time
Some of the time
Rarely
Never
I suffer from unwanted thoughts I cannot control.
*
Most of the Time
Some of the time
Rarely
Never
I think about my problems or mistakes I have made in the past.
*
Most of the Time
Some of the time
Rarely
Never
Go to Top
Subscribe to the KWC Newsletter