Welcome Impact Psychedelic - Impact Psychedelics

Impact Psychedelics

Impact Psychedelics

Impact Psychedelics

First + Last Name^*

Email Address^*

Phone Number^*

What brings you to Impact today?^*

I'm experiencing anxiety

I'm experiencing depression

I'm experiencing PTSD

I'm experiencing Pain

Other:

How often in the past seven days have you felt Pain, Anxiety, Depression, or PTSD ?^*

Never

Rarely

Often

Always

Are you currently prescribed medication for depression, pain, PTSD, or anxiety?^*

Yes

How familiar are you with the benefits of ketamine therapy?^*

I'd never heard about Ketamine therapy until today

I know a bit

I'm very familiar with Ketamine's therapeutic potential

When it comes to learning and personal development, do you prefer structure or do you like to choose your own path?^*

I prefer structure

A little of both

I prefer to choose my own path

In working with a Impact Guide, what style do you prefer?^*

Spiritual

Analytical

A little of both

I'm not sure

Is there a certain area that you are looking for help with (choose all that apply)?^*

Choose

Pain

PTSD

General Anxiety

General Depression

Grief/Loss

Trauma

Addiction

Career Coaching

Family/Couples Problems

Postpartum Depression

Spirituality

LGBTQ+

Other

Do you have a gender preference for your Guide?^*

Male

Female

No preference

Impact 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 Impact.^*

Under 18 years old

Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder)

Prepared for or attempted to end your life (in the past year)

Biological female who is pregnant, nursing, or trying to become pregnant

Method, intent, or plan to commit suicide (in the past month)

None of the above

Where are you?^*

Choose

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

District of Columbia

Delaware

Florida

Finally, how did you hear about us?^*

Social media

Google search

Press

Podcast

Word of mouth

Preferred by Impact client, Impact doctor, therapist or any other provider

Other:

First + Last Name^*

Email Address^*

Phone Number^*

What brings you to Impact today?^*

I'm experiencing anxiety

I'm experiencing depression

I'm experiencing PTSD

I'm experiencing Pain

Other:

How often in the past seven days have you felt Pain, Anxiety, Depression, or PTSD ?^*

Never

Rarely

Often

Always

Are you currently prescribed medication for depression, pain, PTSD, or anxiety?^*

Yes

How familiar are you with the benefits of ketamine therapy?^*

I'd never heard about Ketamine therapy until today

I know a bit

I'm very familiar with Ketamine's therapeutic potential

When it comes to learning and personal development, do you prefer structure or do you like to choose your own path?^*

I prefer structure

A little of both

I prefer to choose my own path

In working with a Impact Guide, what style do you prefer?^*

Spiritual

Analytical

A little of both

I'm not sure

Is there a certain area that you are looking for help with (choose all that apply)?^*

Choose

Pain

PTSD

General Anxiety

General Depression

Grief/Loss

Trauma

Addiction

Career Coaching

Family/Couples Problems

Postpartum Depression

Spirituality

LGBTQ+

Other

Do you have a gender preference for your Guide?^*

Male

Female

No preference

Impact 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 Impact.^*

Under 18 years old

Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder)

Prepared for or attempted to end your life (in the past year)

Biological female who is pregnant, nursing, or trying to become pregnant

Method, intent, or plan to commit suicide (in the past month)

None of the above

Where are you?^*

Choose

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

District of Columbia

Delaware

Florida

Finally, how did you hear about us?^*

Social media

Google search

Press

Podcast

Word of mouth

Preferred by Impact client, Impact doctor, therapist or any other provider

Other:

Impact Psychedelics

Impact Psychedelics

Impact Psychedelics

First + Last Name*

Email Address*

Phone Number*

What brings you to Impact today?*

How often in the past seven days have you felt Pain, Anxiety, Depression, or PTSD ?*

Are you currently prescribed medication for depression, pain, PTSD, or anxiety?*

How familiar are you with the benefits of ketamine therapy?*

When it comes to learning and personal development, do you prefer structure or do you like to choose your own path?*

In working with a Impact Guide, what style do you prefer?*

Is there a certain area that you are looking for help with (choose all that apply)?*

Do you have a gender preference for your Guide?*

Impact 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 Impact.*

Where are you?*

Finally, how did you hear about us?*

First + Last Name*

Email Address*

Phone Number*

What brings you to Impact today?*

How often in the past seven days have you felt Pain, Anxiety, Depression, or PTSD ?*

Are you currently prescribed medication for depression, pain, PTSD, or anxiety?*

How familiar are you with the benefits of ketamine therapy?*

When it comes to learning and personal development, do you prefer structure or do you like to choose your own path?*

In working with a Impact Guide, what style do you prefer?*

Is there a certain area that you are looking for help with (choose all that apply)?*

Do you have a gender preference for your Guide?*

Impact 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 Impact.*

Where are you?*

Finally, how did you hear about us?*

First + Last Name^*

Email Address^*

Phone Number^*

What brings you to Impact today?^*

How often in the past seven days have you felt Pain, Anxiety, Depression, or PTSD ?^*

Are you currently prescribed medication for depression, pain, PTSD, or anxiety?^*

How familiar are you with the benefits of ketamine therapy?^*

When it comes to learning and personal development, do you prefer structure or do you like to choose your own path?^*

In working with a Impact Guide, what style do you prefer?^*

Is there a certain area that you are looking for help with (choose all that apply)?^*

Do you have a gender preference for your Guide?^*

Impact 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 Impact.^*

Where are you?^*

Finally, how did you hear about us?^*

First + Last Name^*

Email Address^*

Phone Number^*

What brings you to Impact today?^*

How often in the past seven days have you felt Pain, Anxiety, Depression, or PTSD ?^*

Are you currently prescribed medication for depression, pain, PTSD, or anxiety?^*

How familiar are you with the benefits of ketamine therapy?^*

When it comes to learning and personal development, do you prefer structure or do you like to choose your own path?^*

In working with a Impact Guide, what style do you prefer?^*

Is there a certain area that you are looking for help with (choose all that apply)?^*

Do you have a gender preference for your Guide?^*

Impact 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 Impact.^*

Where are you?^*

Finally, how did you hear about us?^*