Consent for Ketamine Treatment - Physician
Welcome to Beyond Mental Health Ketamine Treatment Services! We are proud to
operate the only mental health clinic in Hawaii entirely dedicated to the rapid treatment
At Beyond Mental Health, our mission is to treat mental health conditions more
rapidly, more naturally, and with treatments that empower patients to rediscover joy,
adopt a purpose, and kindle hope.
It is very important to us that all patients feel welcomed, safe, supported, and respected,
and we will address any concerns that might arise in this regard. Beyond Mental Health
providers include physicians, psychologists, and therapists. We are governed by certain
laws and regulations and by a code of ethics. The ethics code requires that we make you
aware of certain office policies that may affect you. Please take time to read this
document as it contains important information about our professional services and
business policies. It is also highly recommended for all prospective patients to read
through the information on our website and the more detailed descriptions of
ketamine’s potential and properties as a medication. Please feel free to ask any
questions that may arise.
Our clinical methods are informed by the value we place on safety, respect, mutuality,
inner- directedness, set and setting, non-judgmental awareness and listening, presence,
mindfulness, and the use of non-ordinary states of consciousness in the service of
personal healing and transformation. This treatment opens unexpected opportunities
for insights that may foster creative problem-solving, personal and relational
development and transformation.
Ketamine is an FDA-approved medication used for anesthesia; however, it is used off-label for
the treatment of mood disorders. Participation in this treatment may result in a number of
benefits but there is no guarantee that this will occur.
With ketamine given intramuscularly there is low risk of abscess, infection, muscle
pain and/or soreness at sight of injection.
Common side effects include but are not limited to:
Less common side effects that may occur:
**Consultation and written approval by a cardiologist is required prior to first ketamine
treatment if there is any history of cardiac issues.**
Due to the lack of research of ketamine during pregnancy, receiving treatment while pregnant is
not an option. Females of childbearing age are required to take a Urine Pregnancy Test before
beginning treatment with ketamine. I acknowledge that ketamine can result in birth defects,
fetal death, and/or teratogenicity.
I agree to the following:
I affirm that I have provided a detailed and complete list of all medications and herbal
supplements I am taking as some drugs may interact negatively with ketamine.
I agree to the following guidelines provided below for my pre- and post- ketamine treatment
sessions. I understand that failure to abide by these guidelines can result in medical risk,
postponement, or cancellation of treatment.
Ketamine treatment is an investment in myself, my relationships, and my life. The fee schedule
below is reflective of the combination of education, knowledge, experience, expertise and time
that will given to me during the course of my treatment.
I understand that the above out-of-pocket fee is for off-label ketamine administration, the
ambient dissociative therapy room that my treatment will take place in, as well as the
monitoring and management services during my treatment. If I choose to utilize a talktherapist, that service will be billed to my insurance. I understand that if my insurance does not
pay the full amount that was billed, I then am responsible for that payment. All payments are
due upon arrival.
**I am aware that my physician reserves the right to adjust my fees and that I will be notified at
least 2 weeks prior if any changes are being made.**
I am fully aware, and have been informed that, for my physical safety, my ketamine session
may be monitored on video camera, and that this is required by the clinic. I fully consent to this
recording. I am aware, and have been informed, that my ketamine treatment is neither an
urgent, nor an acute care, nor an emergency treatment, but is instead intended to treat a
chronically depressed mood and/or other chronic longstanding psychiatric issues, and that all
real emergency psychiatric treatments are available at nearby emergency rooms and hospitals. I
am aware, and have been informed, that Dr. Tom Cook’s clinic, Beyond Mental Health, is not
intended to be an urgent care clinic, but is instead an outpatient clinic open on weekdays,
during daylight hours only, and providing an off-label treatment, and I fully consent to this
voluntary, elective arrangement. I acknowledge that there is no guarantee that ketamine will
help my symptoms.
Optional : Psychedelic Guide
I acknowledge that Beyond Mental Health has explained to me that a supportive psychedelic
guide may be offered to sit with me during my treatment, and that this guide has no licensure
or official training in psychotherapy, and is there for comfort, consolation, coordination of care,
and monitoring purposes only. They are not there to provide any counseling, talk therapy or
any other billable clinical services whatsoever. I am fully aware, and have been informed, that if
in my case, this clinic is only providing ketamine, but not comprehensive psychiatric care, and
that if my primary psychiatrist exists elsewhere, then this clinic in no way replaces my primary
psychiatrist, who is still the doctor responsible for my overall care and stability.
If I am unable to attend my scheduled appointment on time, I know that unless I call to
reschedule 48 hours prior, I will be charged the out-of-pocket fee based off of my treatment
selection. I acknowledge that the appointment will be considered cancelled if I arrive more than
15 minutes after my scheduled appointment time. I understand that I will be asked to keep a
credit card on file and will be charged for missed appointments without prior notice or
I understand that if I am pregnant, if I become pregnant, or if I intend to become pregnant while
a patient of Dr. Cook’s Office, I must disclose this information to Dr. Cook’s Office. Failure to do
so will result in a termination of this contract and the doctor-patient relationship.
I acknowledge that I have the right to end treatment at any time without any moral, legal or
financial obligation other than those already accrued. I, too, understand that my physician
reserves the right to terminate treatment at any time without my consent.
By signing below I am acknowledging that I understand and have read the entirety of this
Ketamine Packet, have had my questions answered and concerns addressed to my satisfaction
regarding the ketamine services offered. I have reviewed and fully understand the terms and
conditions of this agreement. I agree to hold Beyond Mental Health free and harmless from any
claims, demands or suits for damages from any injury or complications whatsoever, except for
gross negligence or willful misconduct that may result from such treatment.
My signature indicates that I have either received a copy of this agreement in person or by
email, or have waived the right to receive a copy at my own insistence.
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Document Name: Consent for Ketamine Treatment - Physician
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