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Remote Treatment Agreement

Remote Treatment Overview

Increasing access to safe and effective mental health treatment is core to Mindbloom’s mission, and remote ketamine treatment helps achieve this mission by providing treatment when and where you need it. At your clinician’s discretion, you may be prescribed ketamine for remote treatment. Prescriptions will include no more than six treatments, and your dosage and frequency must adhere to the treatment plan agreed-upon by you and your clinician.

Upon completion of a course of treatment, you and your clinician will determine whether it will be safe and beneficial for you to continue treatment and whether any adjustments to your treatment plan should be made.

Remote Treatment Guidelines

To promote positive outcomes and ensure your safety, we require written confirmation that you’ll comply with all guidelines below.
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  1. Identify a Peer Treatment Monitor (spouse, family member, roommate, friend, or other trusted individual) that will be present and prepared to support each of your ketamine treatments
  2. Follow all of Mindbloom’s preparation for treatment requirements included in the Informed Consent
  3. Do not proceed with a remote session if your blood pressure is above 150/100 or your heart rate is above 100 beats per minute (note: we'll provide you with a digital blood pressure monitor prior to your first treatment)
  4. Set aside at least 2 hours for your uninterrupted treatment, and refrain from moving around until you return to your baseline physical and mental state (if you need to get up for any reason, such as to use the bathroom, ensure that you are escorted by your Peer Treatment Monitor)

If you have any questions about your treatment, email hello@mindbloom.co or call/text your Guide for support. If it’s a medical emergency, call 911.

Zero Tolerance Policy

If you do not comply with this Remote Treatment Agreement, you’ll be disqualified from future ketamine treatment with Mindbloom®. We believe that this policy is essential to ensure your safety and create the greatest likelihood of positive outcomes.

By electronically signing this document, I confirm that:

  1. I have fully read and understand this agreement.
  2. I have had the opportunity to review this document with my clinician and ask questions, and I have received satisfactory answers to my questions.
  3. I will comply with all stipulations included in this agreement and use my medication only as directed by my Mindbloom clinician.
  4. If I break this agreement, I will be disqualified from future ketamine treatment with Mindbloom.

Note: we’ll send you a link to electronically sign this document prior to your first session.