Thank You Life

Provider Network Application

Please note: We are only working with providers who provide in-person sessions.

Your Name *

Your Email *

Business Name *

Business Address *

Website *

Your Role *

Business Information

Private Practice or Clinic? *

U.S.

International

Federal Tax Identification Number *

Person or entity to whom the identification number belongs *

Malpractice insurance provider & coverage *

Malpractice insurance policy number *

Clinical Licensure and Number *

Office address where clients will be seen *

Mailing address where we can send correspondence and payments *

Is office accessible by bus? *

Yes

No

Is office handicap accessible? *

Yes

No

Legal

Have you ever been found guilty of unprofessional, illegal or unethical conduct in a criminal or administrative or judicial proceeding? *

Yes

No

Have you had a professional license or certification denied, probated, suspended, or revoked? *

Yes

No

Have you ever surrendered any license or certification? *

Yes

No

Have you ever been found liable of unprofessional or unethical conduct in a civil lawsuit or proceeding? *

Yes

No

Are claims or charges pending against you for any of the above? *

Yes

No

If you answered YES to any of the preceding questions, you must attach an explanatory statement.

Upload file(s)

Clinical Information

Which medicine(s) do you work with? *

Do you provide ketamine-assisted psychotherapy (KAP)? *

Do you offer in-person sessions? *

When did you begin offering psychedelic-assisted therapy? *

Is your prescriber on-site? *

Yes

No

Who is your prescriber? *

Route of ketamine administration (check all that apply) *

Oral (troches)

IM (intramuscular)

IV (intravenous)

Is the client/patient supervised during the entirety of the session? *

Yes

No

Please outline a typical protocol with your practice. (e.g. screening, intake, prep, medicine session, integration, etc.) *

Which pre- and post- quantitative symptom assessments do you collect? (e.g. PHQ-9, GAD-7, PCL-5) *

Which psychedelic therapy training(s) have you and/or your clinical team completed? *

What is the hourly rate at your practice? (if it varies per staff member, please provide a range) *

What is the cost of a single medicine session? *

Do you currently offer Group Medicine Sessions? *

I Agree

Do you accept insurance? *

Yes

No

Anything else you'd like us to know?

Why is improving access to psychedelic therapy important to you? *

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