--- title: Ketamine Therapy for Depression Intake Form Template | Paperform description: Professional intake form for ketamine therapy patients with treatment-resistant depression screening, psychiatric medication history, dissociative experience assessment, and safety monitoring. url: "https://paperform.co/templates/ketamine-therapy-for-depression-patient-intake-form" type: static generatedAt: "2026-04-04T00:44:23.892Z" --- [← Back to free form templates](/templates/) ![Ketamine Therapy for Depression - Patient Intake Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/ketamine-therapy-for-depression-patient-intake-form.png) [Preview](https://_preview.paperform.co/ai-template/ketamine-therapy-for-depression-patient-intake-form) [Use this template for free](/create?ai-template=ketamine-therapy-for-depression-patient-intake-form) [Intake Forms](/templates/category/intake-forms/)[Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/)[Mental Health](/templates/industry/mental-health/) [Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Therapist](/templates/role/therapist/)[Counselor](/templates/role/counselor/)[Psychologist](/templates/role/psychologist/)[Healthcare Administrator](/templates/role/healthcare-admin/) About this free form template ### Streamline Your Ketamine Therapy Intake Process If you're a mental health clinic, psychiatry practice, or integrative wellness center offering ketamine therapy for treatment-resistant depression, this intake form is designed specifically for your workflow. Paperform makes it easy to collect comprehensive patient histories, screen for contraindications, and ensure safety protocols are followed—all before the first appointment. #### Why This Template Works for Ketamine Therapy Providers Ketamine therapy requires careful patient evaluation, including detailed psychiatric medication history, dissociative experience screening, and medical contraindication assessment. This template captures all essential information in one professional, HIPAA-aware workflow that feels supportive rather than clinical. With conditional logic built in, you'll only ask relevant follow-up questions based on patient responses—reducing form fatigue while ensuring you get the depth you need for treatment planning. The clean, calming design helps anxious patients feel comfortable sharing sensitive mental health information. #### Built for Mental Health Professionals Whether you're a psychiatrist, psychiatric nurse practitioner, licensed therapist working alongside prescribers, or clinic administrator, this form handles: - **Treatment-resistant depression history** with details on previous medication trials and outcomes - **Current psychiatric medications** and dosages for safety review - **Dissociative experience screening** to assess patient risk factors - **Medical history and contraindications** including cardiovascular, liver, and substance use concerns - **Emergency contact and safety planning** information - **Informed consent acknowledgment** for treatment protocols #### Automate What Comes Next with Stepper After a patient submits their intake form, [Stepper](https://stepper.io) can automatically route the information to your EHR system, notify your clinical team, schedule a pre-treatment consultation, and send preparatory materials to the patient. You can build multi-step approval workflows for treatment eligibility or trigger different care pathways based on screening responses—no developer needed. #### Professional, Secure, and Conversion-Optimized Paperform is SOC 2 Type II certified and designed to handle sensitive health information with care. Your forms can match your practice's branding, embed seamlessly on your website, or live on their own custom domain. With Paperform's multi-page layout, patients can complete intake at their own pace without feeling overwhelmed. Trusted by hundreds of mental health practices and integrative clinics, this template helps you deliver compassionate, evidence-based ketamine therapy while maintaining the clinical rigor your practice demands. Built for growing businesses, trusted by bigger ones. Trusted by 500K+ business owners and creators, and hundreds of millions of respondents. ![Capterra - 4.8 out of 5](/images/capterra-st.jpg) ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg) ![G2 - 4.8 out of 5](/images/g2-st.jpg) [Try Paperform free now](/register) ## More templates like this [![Residential Treatment Center Admission Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/residential-treatment-center-admission-form.png) ### Residential Treatment Center Admission Form A comprehensive intake form for residential treatment centers to collect client information, psychiatric history, medication details, and family therapy needs for mental health and behavioral health admissions.](/templates/residential-treatment-center-admission-form/) [![Memory Clinic Cognitive Assessment Intake 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