Name
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First Name
Last Name
Email
*
Phone
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(###)
###
####
May we leave a message?
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Yes
No
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about this retreat?
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Gender
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Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
Pronouns
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Current Occupation
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Current Relationship Status
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Single (never married)
Married, or in a domestic partnership
Widowed
Divorced
Separated
Person to alert in the event of medical emergency
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Primary Care Physician
*
Current Medical and Psychiatric Issues
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Past Medical and Psychiatric Issues
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Current Medications
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Past Medications
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Allergies (including food)
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Current Height and Weight
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Sleep habits or problems
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Diet type
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How often/amount do you drink alcohol?
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Have you had a dependency on alcohol or recreational drugs?
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Yes
No
Have you ever or do you now have a history of prescription drug dependency or abuse?
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Yes
No
Are you currently pregnant or planning to become pregnant?
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Yes
No
Do you receive psychotherapy or counseling now or in the past?
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Yes
No
Do you have a spiritual practice?
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Yes
No
Do you have prior experience with non-ordinary states of consciousness?
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Yes
No
If so, please specify what kinds of experiences (psychedelics, breathwork, authentic movement, shamanic journeying, trance states)? And what influence have these experiences had on your life?
Have you had any challenging or problematic experiences?
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What are your concerns about doing ketamine?
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What do you hope to gain from this experience?
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Please list with dates any significant trauma you have experienced: violence—physical, sexual, emotional; abuse; natural occurrences; etc. Please comment on any lingering feelings or symptoms such as those that occur with PTSD.
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Have you ever been hospitalized for a psychological difficulty?
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Have you been having thoughts that you would be better off dead or of hurting yourself in some way?
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What is the nature of your social/personal support system in your life? (i.e. partners, friends, family that you can call and rely upon for help and support?
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What is your sense of your coping mechanisms?
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What strategies do you utilize to deal with stress and life’s challenges?
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What friend, loved one, counselor or other trusted person(s) will you speak with about this retreat?
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What are their dispositions towards you pursuing this experience? Are they supportive?
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What practices do you feel will be most beneficial in helping you to integrate this experience into your life?
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What resources do you have access to for supporting your integration and how will you put them to use?
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