Mom Parts Intensive: Inquiry Form

Thank you for your interest in the Mom Parts Intensive. Please take a few minutes to complete this form thoughtfully. Your responses help Jessica understand what you're bringing into the journey and help determine whether an intensive is the right fit before scheduling your consultation call. You can expect to hear back within three to five business days.

First name

Last name

Email

Phone number

Where are you Located? And are you willing to travel to California for all your sessions?

I am located in California.

I am located outside California and am willing to travel for sessions.

I am located outside California and am not able to travel — I understand I may not be eligible for this service.

Please Note: all sessions take place via telehealth. Clients must be physically present in California for all sessions.

Which track are you interested in?

If you selected the KAP track: what is your current ketamine status? This helps us think through timing together.

I have a current prescription AND the medicine in hand. I'm ready to proceed.

I have a current prescription but do not yet have the medicine.

I do not have a prescription. I would need a referral to a prescribing provider

I'm not sure what I have. I'd like to discuss this on the consultation call.

Not applicable. I'm interested in the non-KAP track

Please note: if you need a prescription and/or medicine, the process typically takes several weeks. Jessica can provide a referral to a prescribing provider if needed. We'll factor this into your scheduling on your consultation call.

Have you done any previous therapy or medicine work? (This isn't a requirement, just helpful context).

Are you currently working with a therapist or other mental health provider?

Yes

No

If yes, are they aware you're seeking this additional support?

What is bringing you to this work right now?

The Mom Parts Intensive is designed as one meaningful part of a larger healing journey, a powerful opening, not a complete solution. With that in mind: what are you hoping to gain or discover through this experience?

Is there anything in your current mental or emotional state that you'd want Jessica to know before your consultation call?