Name *

First Name

Last Name

What brings you to Ignite? *

OCD Concerns

Trauma / PTSD

Substance Use Concerns

Life Transitions

Impulse control concerns

Grief and Loss

Perinatal and Postpartum

Parenting

Mood, Anxiety, Depression

Other (please elaborate below):

Ketamine Integration Psychotherapy (if you have a current Ketamine prescriber, please note in Other, below):

Preferred Method of Communication to confirm consultation *

Phone

Email