Important Notice

Submitting this form does not establish a physician-patient, therapist-client, or provider-patient relationship with Althea NOLA or any of its clinicians. This form is for informational and scheduling purposes only. Eligibility for Ketamine-Assisted Psychotherapy is determined solely through a formal clinical assessment conducted by our medical team.

The information you provide will be used only to respond to your inquiry. This form is not a secure clinical communication channel — please do not include sensitive medical details, diagnoses, or medication information. That information will be collected securely during the clinical intake process.

If you are experiencing a medical or mental health emergency, please call 911 (medical) or 988 (Suicide & Crisis Lifeline), or go to your nearest emergency room. This form is not monitored for emergencies.