Best Ketamine Clinics Quiz

1
Please tell us about how you felt over the past 7 days * This field is required.
Never
Rarely
Sometimes
Often
Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
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2
Please tell us about how you felt over the past 7 days * This field is required.
Never
Rarely
Sometimes
Often
Always
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
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3
Are you currently prescribed medication for depression or anxiety?* This field is required.
Yes, for depression
Yes, for anxiety
Yes, for both
Nope
4
What's your email?* This field is required.
5
Do any of the following apply to you?* This field is required.Ketamine therapy isn't a 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 911, or go to the nearest emergency room. Responses are not monitored in real-time by BestKetamineClinics.com.
Under 18 years old
Primary psychotic disorder (e.g., schizophrenia, schizoaffective disorder)
Prepared for or attempted to end your life (in the past year)
Method, intent, or plan to commit suicide (in the past month)
Biological female who is pregnant, nursing, or trying to become pregnant
None of the above
6
Which state are you in?* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
7
Thank you! Let's set up a 15 minute FREE consultation to give you a chance to learn more about ketamine therapy. We will do our best to answer all of your questions. We will need to ask your name, phone and email (again) here Please use the same email you submitted above
8
How did you hear about us?* This field is required.Please select all that apply.
Word of mouth
Referred by my medical provider
Referred by a BestKetamineClinics client
Google search
Social media
Outdoor poster
Press
Podcast
9
By checking this box, I agree to the Terms of Use (https://bestketamineclinics.com/terms-of-use/)* This field is required.
By checking this box, I agree to the Terms of Use
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