Informed consent

Background

HAPPŸŸ LLC is a technology platform and solution that assists independently owned and operated affiliated medical practitioners and practices in their ability to provide mental health services to clients and potential clients. On the HAPPŸŸ website, you can find the states in which they operate. One of the affiliated medical providers that operate in your state is the provider that will be providing services to you (hereinafter referred to as “Provider”). Provider information will be provided to each patient during their consultation. 

Using telehealth, the Provider provides psychiatric treatment services. You may be prescribed a medicine named ketamine, a Schedule III medication that has been used for various medical reasons since it was initially FDA-approved in 1970, as part of these psychiatric treatment services. 

What is Ketamine

Ketamine is a synthetic pharmaceutical compound, classified as a dissociative anesthetic. It is one of the most widely used drugs in modern medicine and is on the World Health Organization’s List of Essential Medicines. It was developed in 1963, FDA approved in 1970, and adopted by many hospitals and medical offices because of its rapid onset, proven safety, and short duration of action.

Ketamine is most commonly used in surgical settings, including pediatric surgery, due to its excellent safety profile, particularly around breathing/airway management. It has also been utilized successfully in managing acute and chronic pain conditions due to its analgesic properties.

In the last two decades, ketamine has been increasingly clinically applied at subanesthetic doses as an off-label treatment for various chronic treatment-resistant mental health conditions, such as depression, alcoholism, substance dependencies, post-traumatic stress disorder, obsessive-compulsive disorder, and other psychiatric diagnoses.

Non-medical and recreational use of ketamine began in the late 1970s, leading to its cultural reputation as a club/party drug; it was also enthusiastically adopted by the psychedelic community and others who value exploration of altered states.

How Ketamine Works

As mentioned, ketamine is classified as a dissociative anesthetic, where “dissociation” means a sense of disconnection between mind and body, and from one’s ordinary reality and usual sense of self.

The present understanding of ketamine’s mode of action is as an NMDA antagonist working through the glutamate neurotransmitter system. (This is a different pathway than that of other psychiatric drugs such as the SSRIs, SNRIs, lamotrigine, antipsychotics, benzodiazepines, etc.)

In depression, the spindly receptors on neurons that facilitate signal transmission may recede, and the amygdala and hippocampus (both which help govern mood) may shrink. Animal research has shown that ketamine can stimulate neural growth within days (and sometimes hours). One hypothesis is that there is similar action in Humans.

Another hypothesis is that ketamine affords a reprieve from habitual patterns of thought that underlie mood and behavior, thereby creating an opportunity for learning new and healthier patterns of thought. There is no current consensus on mode of action, and other mechanisms may be found central to ketamine’s effects.

Dosing Strategies and Routes of Administration

Ketamine can be administered in a variety of ways, including as an intravenous infusion (IV), intramuscular injection (IM), a subcutaneous injection (SC), intranasally, or sublingually/orally as a dissolving troche or tablet. Routes vary in the onset, bioavailability, and duration of active effects for each person.

Though research has demonstrated an antidepressant response to low doses that are minimally psychoactive or sub-psychedelic, this effect tends to be cumulative, requiring repeated administrations over short periods of time. Some practitioners view the psychedelic and dissociative experiences that occur at higher doses to provide a more robust and longer-lasting outcome.

Though experiences vary greatly, it is generally thought that lower doses provide empathogen-like (heart-opening) responses, while higher doses create dissociative, psychedelic, out-of-body, ego-dissolving peak responses.

There are a number of factors that determine the choice of dose and route of  administration, including client preference, prior exposure to ketamine, therapeutic goals, experience with other psychedelics, body height, weight, and sensitivity. Those without prior experiences are advised to begin with lower doses to reduce anxiety and build familiarity with ketamine’s effects, while those who are experienced with psychedelics may begin with higher initial doses. The dose and route of administration are ultimately decided by the Provider, who will discuss the plan with you before the session.

The Ketamine Experience

The ketamine experience is characterized by the relaxation of ordinary concerns

and usual mindset, all while maintaining conscious awareness. This tends to lead to

a disruption of negative feelings and preoccupations. Some ketamine providers feel

that this interruption–and the exploration of other possible states of consciousness–can lead to significant shifts in overall well-being.

At lower doses, you will most likely experience mild anesthetic, anxiolytic, antidepressant, and psychoactive effects. You might experience increased sensitivity to light and sound, as well as an altered sense of time. Some people experience empathogenic (similar to MDMA) effects in this dose range. This state may also enhance participation in psychotherapy, as defenses are relaxed, yet communication with others is still possible.

Higher doses are more likely to produce psychedelic, dissociative states that are largely internal journeys away from the external world. Body sensations are greatly diminished. Such journeys may provide a more robust treatment effect, often assisting in the resolution of existential concerns, accelerating psychological and (and possibly spiritual) growth, and promoting a positive change in outlook and character that we refer to as a transformative response.

Sensory effects of ketamine may include distorted visualization of colors, feeling suspended in space or floating, experiencing out-of-body sensations, vivid dreaming, and changes in visual, tactile and and auditory processing. Synesthesia (a mingling of the senses) may occur. Familiar music may not be recognizable. An ordinary sense of time may morph into time dilation.

These effects typically start 5 to 10 minutes after ketamine dosing. The peak effects typically last 20 to 30 minutes, and then slowly diminish for the next hour. Some alterations in sensory perception, speech, and motor ability may continue for approximately 5 hours.

Throughout the ketamine session you will have access to an audio track that will have meditation, exercises, and/or music. During these sessions, it is recommended that you wear an eye mask to facilitate and enhance the experience, and to help you maintain an internal focus. We recommend that you speak as little as possible while experiencing the active effects of this dose of ketamine, as it may be more beneficial for you to stay with the experience. 

The moments following an altered state can be exquisitely poignant and powerful in their ability to evoke and reshape how we attach to others, and your providers regard this opportunity with the importance it deserves.

You will be welcomed to share about your experience and discuss any insights or

alternative perspectives that you discovered with your peer monitor; however, some choose to contemplate their experience quietly and discuss at a later integration session. Whatever decision you make in these moments should be respected.

Ketamine Treatment

During your initial video consultation, your Provider will conduct a psychiatric evaluation, determine whether you have a diagnosis that qualifies you for treatment using this medication, and confirm that you do not meet any of the criteria for exclusion. If your Provider determines that you are eligible for treatment, they will review this Informed Consent with you and provide an opportunity for you to ask any questions.

‍Your Provider may prescribe sublingual ketamine tablets. The tablets are administered by placing them under your tongue or in between your cheek and gums for 15 minutes without swallowing and then spitting out any saliva that has accumulated. Ketamine that is ingested orally may have a longer onset time, increase the adverse effects, and/or extend the time required for you to return to your baseline physical and mental states.

‍The effects of the ketamine tablets can typically be observed approximately 10 minutes after administration,with the peak experience approximately 30-45 minutes thereafter. About an hour after taking the medication, the effects of ketamine will begin to diminish. The side effects of ketamine, such as dissociation, dizziness, headache, anxiety, or nausea, may persist for several hours following treatment.

Guides

As part of your program you may work with a Guide who is affiliated with HAPPŸŸ. Your Guide can help you navigate your program, set intentions, and develop your integration plan. Guides are trained in life coaching, best practices for working with psychedelic medicine, and how to best collaborate with your clinician to support your treatment. 

‍While your Guide may be able to support you in changing unwanted thoughts or behaviors and achieve the goals you set for your program, Guides are not licensed therapists, so they are not licensed to treat anxiety, depression, or other diagnoses. That’s the role of your clinician or other licensed mental healthcare provider you may work with outside of this treatment. 

‍Guides aim to reply to client messages within 48 hours (or much sooner), but they do not provide 24/7 support.

Eligibility for at-home ketamine

Before participating in ketamine treatment, your Provider will carefully review the intake information your completed, including the answers regarding your medical history and your responses to the various assessments administered. At their sole discretion, your Provider may require an in-person physical and/or psychiatric consult to confirm your eligibility for treatment and diagnosis. For at-home ketamine therapy with HAPPŸŸ, Clients must be at least 18 years old and cannot meet the exclusion criteria below:

1. Allergies to ketamine.
2. Alcohol or substance use dependence.
3. History of opioid use disorder.
4. Active psychotic, manic, or mixed symptoms or history of psychotic symptoms.
5. Untreated high blood pressure.
6. Congestive heart failure or other serious cardiac problems.
7. Severe breathing problems.
8. Unstable thyroid disease.
9. Elevated intraocular pressure/glaucoma.
10. Elevated intracranial pressure.
11. Other serious medical illnesses.
12. Pregnancy, nursing, or currently trying to become pregnant.
13. Active suicidal ideation with the method, intent, or plan within the past month or a suicide attempt within the past year.
14. Any other aspect of the patient’s psychiatric history, outpatient support system, or home environment that would render at-home treatment psychologically unsafe in the opinion of the prescribing clinician, including a history of severe and unresolved trauma.

If there are any changes to your physical or mental health that impact your eligibility for treatment. you are required to notify your provider immediately and discontinue treatment.

Client Requirements for Treatment

To participate in ketamine treatments, you are obligated to comply with the following guidelines:

1. 1. Peer Monitor: Each client must identify and have present a peer monitor during their treatment. Typically these are a partner, family member, close friend, roommate, or other trusted person over 18 years of age.
   2. Stimulants: To avoid mild agitation and/or blood pressure elevation, avoid stimulants on the day of treatment. Stimulants may be resumed following your ketamine session.
   3. Benzodiazepines: So long as there is no risk to your health and safety, it is recommended that you avoid benzodiazepines on the day of treatment as they diminish your response to ketamine.
   4. Alcohol: To promote your safety and the likelihood of a strong clinical response, you need to avoid alcohol or the effects of alcohol (i.e. a hangover) on the day of your treatment. 
   5. Fasting: To mitigate the risk of nausea and to have the most impactful results, please refrain from consuming food for 3 hours prior to treatment. Your Provider may, at their discretion, prescribe anti-nausea medication.
   6. Liquids: To avoid bathroom breaks that may disrupt your treatment, do not drink any liquids for 1 hour prior to your treatment.
   7. Blood pressure: Ketamine may raise your blood pressure. For your safety, do not proceed with treatment if your blood pressure is above 150/100 or your heart rate is above 100 beats per minute 
   8. Time: While most ketamine sessions last about an hour, set aside at least 2 hours for your treatment. Avoid moving around until you return to your baseline physical and mental states. In the event of your need to get up for any reason, please ask your peer monitor for assistance.  
   9. Vehicles/Machinery: Do not operate any vehicle or heavy machinery until the day following your treatment.

• Primary Care: You are required to be under the care of a primary care physician to evaluate your overall health, and in particular your respiratory and cardiovascular status.

Some medical and psychiatric conditions need to be treated before you can safely

take ketamine. These conditions include hallucinations, untreated mania, unstable

angina (chest pain/heart disease), uncontrolled hyperthyroidism, increased

intracranial pressure, evidence of liver disease, or a previously demonstrated

allergy to ketamine.

An EKG may be required for those with a history of arrhythmia or a history of

serious uncontrollable cardiovascular issues. Untreated or uncontrolled hypertension is a contraindication to ketamine use as the substance causes a rise in blood pressure. This increase is typically comparable to normal increases in blood pressure that occur with heavy exercise.

Pregnant women and nursing mothers are not eligible because of undetermined

potential effects on the fetus or nursing child.

Those with a history of cystitis or other bladder issues may need to be cleared

by urological consultation, due to the rare but potentially significant adverse effect

of cystitis.

Those with a primary psychotic or dissociative disorder or who are currently in a manic or mixed episode are not eligible for treatment with ketamine. Please consult your treating Provider if you are taking anxiety medications such as benzodiazepines, pregabalin, or gabapentin as they may blunt the antidepressant effects of ketamine.  Opiates cannot be taken concurrently with ketamine therapy.

Information on ketamine’s interaction with other medicines is only partially available; any possible interactions will be assessed to help determine your eligibility for ketamine treatment.

Why Ketamine Assisted Therapy (KAT)?

The administration of ketamine may be most effective when paired with additional therapeutic activities. While not providing psychotherapy, HAPPŸŸ offers a therapeutic program that will prepare you for your ketamine sessions, encourage you to explore your mind while within the ketamine space, and assist you in integrating your experiences afterwards. This program emphasizes the potential for change, and such change is best facilitated within a structured, supportive therapeutic environment with providers who are aware of your issues, hopes, desires, and struggles.

Ketamine has the potential to create a non-ordinary state of consciousness, facilitating a profound transpersonal or mystical peak experience. These sorts of peak experiences have been shown to expand one’s sense of self and understanding of existence, and may enable you to access your own healing wisdom. Your therapeutic teams serve as Guides, not licensed therapists, and assist in processing the experience and its impact on your everyday life.

Ketamine’s altered state can create conditions of relational and psychological openness, and thus we believe that trust in your providers enables the deepest possible work to occur. Preparation and integration sessions are meant to build that sense of connection and trust between you and your guides.

Many have found it beneficial to set an intention for the experience. Intentions should be personal and focused, which could include alterations in habits (such as the use of alcohol or cannabis, exercising, etc.), shifts in self-defeating patterns of thought or social interactions, or exploration of spiritual/existential realms. Our team will work with you to formulate your goals, and will also encourage you to hold those lightly, as resistance or attempts to control the experience can produce anxiety.

Your experience will be unique to you, and each of your sessions will be different. All such journeys are adventures that cannot be programmed. They evolve from your own being in relation to this medicine, and it is best to relax into the path that unfolds. Many enjoy the journey, while others do not. Everyone comes through it, and often with greater insight into themselves and their lives. Our therapeutic program is designed to assist you in integrating these insights into your daily functioning.

As a byproduct of your experience, you may feel improvement in your emotional state and reduction in symptoms such as depression, anxiety, and post-traumatic manifestations. You may notice that you are a bit different after a ketamine experience, and that difference may feel liberating, allowing for new perspectives and behavior.

These shifts may happen during treatment, in the aftermath, and/or in the days and weeks that follow. Some experiences may be temporarily disturbing to you, and we will work to help you understand these in context of your healing process. Ultimately, we are working to assist you in changing patterns of mind, mood, and behavior that cause you difficulty and distress. 

Both our therapeutics and medication (including psychedelic medicines) are effective, but the combination has been shown to be much more powerful than either on its own. Many come to us having attempted numerous treatments, and we want to ensure that you have the best possible outcome for your investment. This is a unique opportunity for growth and change, and so we encourage you to actively engage in the therapeutic process as well as the medication administration.

When Will I See Positive Effects, and How Long Will They Last?

Ketamine treatment can result in a number of benefits, and there are now many studies demonstrating its efficacy; however, it is still a relatively new and experimental psychiatric intervention, and there are no guarantees of your outcome.

Ketamine is distinguished from other psychotropic medications by its rapid onset, often producing relief in as soon as a few hours. The literature indicates a 85% initial response rate to ketamine, as well as a remission rate (return of symptoms) for people with treatment-resistant depression of 40-50%.

Durable improvement generally occurs with more than one administration, and is most robust when part of an overall treatment program. It may not permanently relieve your condition. If your symptoms respond to ketamine, you may still elect to be treated with other medications and ongoing psychotherapy to reduce the possibility of relapse. Over time, you may also need additional ketamine booster administrations or other therapies to maintain your remission. 

It is common to not respond to ketamine after the first administration. HAPPŸŸ’s program starts with a minimum of 6 dosings. If you do not respond after a series of 6 dosings, additional ketamine will not be offered. Studies have shown it is not effective to keep repeating ketamine in those who do not respond to the first doses. 

Although a course of ketamine treatment typically provides only a few months of benefit, repeated treatments have been shown to have a cumulative effect, prolonging mood improvements, and current research is focused on how to sustain these benefits with an optimal dosing schedule and integration of therapeutic activities.

This is an effective medicine, and it is even more so when you work with it to create

positive changes in your life that can sustain your recovery.

Monitoring Progress

Upon signing up, you will be enrolled in our electronic survey program. This system will send you several brief online measures of your symptoms and general functioning, which you will need to complete periodically.

Side Effects and Risks Associated with Ketamine Treatment

Ketamine has an extensive record of safety and has been used at much higher doses for surgical anesthesia, without respiratory depression. As with any other medication, there are also some potential risks and side effects to be informed of and consider.

The most common physical side effect is a short-term spike in blood pressure, pulse, or heart rate, which may be a risk to those with heart disease, and can be misinterpreted as a symptom of anxiety.

Other possibilities for side effects include dizziness/lightheadedness, sedation, impaired balance and coordination, slurred speech, mental confusion, excitability, diminished ability to see things that are actually present, diminished ability to hear or to feel objects accurately including one’s own body, headache, anxiety, nausea, vomiting, and diminished awareness of physical functions such as respiration. These effects are transient and resolve as the active phase of the medication ends (generally within 4 hours).

‍While ketamine has been reported to produce adverse outcomes including but not limited to those outlined below, lasting adverse side-effects are rare when medical protocols are carefully followed. By signing this informed consent document, you agree to adhere to HAPPŸŸ’s treatment guidelines, which are designed to minimize the risk of adverse outcomes associated with the use of ketamine and to maximize its potential benefits.

• While ketamine has not been shown to be physically addictive, it has been shown to cause psychological dependency in some frequent recreational users
• In rare cases, frequent, heavy users have reported increased frequency of urination, urinary incontinence, pain urinating, passing blood in the urine, or reduced bladder size
• Ketamine may worsen problems in people with schizophrenia, severe personality disorders, or other serious mental disorders; users with a personal or family history of psychosis should be cautious using any psychoactive substance, including ketamine, and discuss potential risks with your clinician before proceeding with treatment
• The dissociative effects of ketamine may increase vulnerability and the risk of accidents
• People with a personal history of schizophrenia, schizoaffective disorder, or other primary psychotic illnesses are not eligible for ketamine therapy, due to the risk for ketamine to exacerbate psychotic symptoms in susceptible individuals

Potential for Ketamine Abuse and Physical Dependence

Ketamine belongs to the same group of chemicals as phencyclidine (Sernyl, PCP, “Angel dust”). This group of chemical compounds is known chemically as arylcyclohexylamines and are classified as hallucinogens (also known as psychedelics). Ketamine is a controlled substance and is subject to Schedule III rules under the Controlled Substance Act of 1970. Medical evidence regarding the issue of drug abuse and dependence suggests that ketamine’s abuse potential is equivalent to that of phencyclidine and other hallucinogenic substances.

Phencyclidine and other hallucinogenic compounds do not meet the criteria for chemical dependence, since they do not cause tolerance and withdrawal symptoms. However, cravings have been reported by individuals with a history of heavy use of psychedelic drugs. In addition, ketamine can have effects on mood (feelings), cognition (thinking), and perception (imagery) that may make some people want to use it repeatedly.

Therefore, ketamine should never be used except under the direct supervision of a licensed Provider. We have not had clients become dependent on ketamine.

Consent to Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations and, at times, from different practices, to share individual client medical information for the purpose of improving client care. Telehealth services offered through the HAPPŸŸ platform by Providers may include consultations by video or by phone, chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as client education. The information you provide may be used for diagnosis, therapy, follow-up and/or client education, and may be provided through any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with asynchronous communications; and (5) output data from medical devices and sound and video files.

‍The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. It is possible, though unlikely, that your information or data may be lost due to technical failures. You agree to hold HAPPŸŸ and Provider harmless against any information or data that is lost due to technical failures.

‍The Providers are an addition to, and not a replacement for, your primary care physician and/or primary mental health provider. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

‍Expected Benefits:

• Improved access to care
• More efficient care evaluation and management

‍Possible Risks: 

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies
• In rare events, a provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a visit with your local primary care doctor
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information
• In rare events, a lack of access to complete medical records may result in inaccurate and/or incomplete medical advice.

Alternative Procedures and Treatment

Psychotherapy without ketamine is available and can be effective. Major Depression

(MDD), PTSD and Bipolar Disorders are usually treated with antidepressant medications, tranquilizers, mood stabilizers and psychotherapy. PTSD is often also

treated with Eye Movement Desensitization and Reprocessing (EMDR). Electroconvulsive therapy (ECT), and the recently introduced Transcranial Magnetic Stimulation (TMS) are also in use for treatment-resistant depression.

Before deciding to proceed with at-home ketamine treatment and a telehealth consultation, you should also consider alternatives such as in-person services. You can discuss these alternative treatments with your Provider or with your local primary care doctor.

Voluntary Nature of Participation

Your decision to undertake KAT is completely voluntary. Once you indicate that you have understood the benefits and risks of this treatment, you will be asked to sign the Informed Consent Agreement at your first visit in order to participate.

You may ask us any questions you may have concerning the procedure or effects of ketamine at any time. Your consent to receive ketamine may be withdrawn by you, and you may discontinue your participation, at any time up until the lozenge has been taken.

By signing the Informed Consent for Ketamine Assisted Therapy , you indicate that you understand the information provided, that any questions or concerns you have regarding our services or this agreement have been answered and resolved, and that you give your consent to the therapeutic procedures to be performed during your participation in KAT.

Confidentiality

Your privacy is a priority and all treatment records will be kept confidential. They will be maintained with the same precautions as ordinary medical records. If you would like to provide other individuals or organizations with access to your records, contact us for a release form. You also understand that your healthcare information may be shared by Provider with HAPPŸŸ, other Providers, and with other individuals for scheduling, treatment, and/or billing purposes, as well as in the event of a malpractice suit or other litigation, or for any other purpose to the extent permitted by law. Your anonymized patient data with all patient identifiable information removed may be used for research purposes. Please refer to the Privacy Policy and Notice of Privacy Providers for additional details.

By electronically signing this document, I confirm that:

1. I have fully read and understand this agreement. I understand the potential benefits, risks, and alternative treatment options, and I freely give my consent to participate in ketamine treatment and receive services via telehealth from Provider providers affiliated with HAPPŸŸ.
2. I will abide by all of HAPPŸŸ’s guidelines and requirements outlined in this document and/or those that have been communicated by my Provider.
3. I meet the eligibility criteria and do not meet the exclusion criteria listed in the “Eligibility” section above. If there are any changes to my physical or mental health that impact my eligibility for treatment, I will notify my Provider and HAPPŸŸ immediately and discontinue treatment, if necessary.
4. I will be physically located in my state of residence, as identified in my new client registration, during my telehealth consultation. I will notify my Provider and HAPPŸŸ immediately and no later than at the beginning of your telehealth consultation if I am located in a different state.
5. I understand that neither my Provider or HAPPŸŸ is not able to connect me directly to any emergency services. If I am in a life-threatening situation, I will call the National Suicide Prevention Line at +1 1-800-273-8255, call 911, or go to the nearest emergency room.
6. I understand it is up to the Provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter. The Provider may deny care for potential misuse of the telehealth services or for any other reason if, in the professional judgment of the Provider, the telehealth encounter is not medically or ethically appropriate.
7. I understand that my healthcare information may be shared with other individuals for the purposes of treatment, scheduling, billing, and other healthcare operations.
8. I understand that I have the right to object to the videotaping or other recording of a telemedicine visit, and I also agree not to record a telemedicine visit without my provider’s permission.
9. I give HAPPŸŸ and Provider permission to access information regarding my historical medical data through their electronic health record system.
10. I understand that if I participate in a consultation, I have the right to request a copy of my medical records and to request that a copy of my medical records be sent to my local primary care physician or another medical provider.
11. I understand that I may register any complaints regarding my provider to the applicable state professional licensing board.
12. I understand that I may withdraw my consent from treatment and/or the use of telehealth at any time by providing notice to support@happyy.com. I understand that my revocation of consent may result in me no longer qualifying to receive services and that such consent will not impact the rights and actions of HAPPŸŸ and Provider while the consent was in effect. 
13. I understand that I will have the opportunity to ask my Provider questions about this consent form at any time during my treatment. I understand that I may revoke this consent by following the process set forth in item 12 located above.

Thank you for taking the time to read this important information

By signing this Informed Consent for Ketamine-Assisted Therapy (KAT), you indicate that you understand the information provided, that any questions or concerns you have regarding our services or this agreement have been answered and resolved and that you give your consent to the therapeutic procedures to be performed during your participation in KAT. 

You agree to maintain contact with your treatment team throughout treatment by attending scheduled appointments, responding to communications from your treatment team, and informing your treatment team promptly in case of aggravation of symptoms such as an increase in suicidality. 

You acknowledge that psychedelic-assisted therapy has the potential to create psychological and emotional destabilization resulting in reduced functioning. Typically these symptoms are short-term in duration, but in some cases can last for longer time periods.  

By signing this document you are acknowledging the risks of this treatment.