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SCREENING AND READINESS QUESTIONNAIRE

Before scheduling your Clarity Call, please complete this Screening Questionnaire so we can better understand your goals, determine if the program is the right fit, and make the most of our time together.

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Basic Information

Full Name *

Phone *

Date of birth *

Sex *

Male

Female

Other

Address

Street Address *

City *

State *

Country *

Postal Code *

Email *

How did you hear about Elixir? *

Financial & Logistical Readiness

The 12-week Overdrive to Ease Evolution program investment is $7,777 pay in full and $8,333 for payment plans (financed via Klarna) *

I understand and am financially prepared for this investment

I would like to discuss payment plan options

I am not currently in a position to invest

All ketamine experiences take place in-person in Bend, Oregon, while coaching and integration sessions may occur via telehealth. *

I live near Bend or am able to travel for my sessions

I cannot travel to Bend at this time

12 Week Program Schedule

The program includes weekly participation for 12 weeks, including appointments and home practices. If you do not want to engage in the full three ketamine experiences, you are welcome to swap out 60-minutes of coaching instead.

Week 1: Intake/Introduction - 45 minutes

Week 2: Ketamine Experience (2-3 hours)

Week 3: Integration - 60 minutes

Week 4: Coaching Session - 30 minutes

Week 5: Coaching Session - 30 minutes

Week 6: Ketamine Experience (2-3 hours)

Week 7: Integration - 60 minutes

Week 8: Coaching Session - 30 minutes

Week 9: Coaching Session - 30 minutes

Week 10: Ketamine Experience (2-3 hours)

Week 11: Integration - 60 minutes

Week 12: Coaching Session (Next Steps) - 60 minutes

Program schedule agreement *

I can commit to this level of engagement

I cannot commit to this level of engagement at this time.

Informed Consent & Readiness to Proceed

I understand that this program includes both medical and therapeutic components, and participation depends on clinical clearance.

I understand that ketamine is not suitable for everyone and that medical screening is required prior to enrollment.

I acknowledge that true transformation requires personal commitment to integration practices, not just the ketamine experience.

Acknowledgement *

I’ve read and understand the above, and would like to proceed and book a no-obligation / no cost discovery call if eligible.

Signature *

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