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Ketamine-Assisted Psychotherapy Retreat Intake
Hello and thank you for your interest in our KAP retreat. Please take a moment to fill out the following form. We want to make completely sure that this is a good match for your needs and history. If you prefer to speak with someone directly instead, please go back to the
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Email
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Your email
Name
*
Your answer
State of Residence
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Your answer
Email Address
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Your answer
How did you hear about our KAP Retreat?
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Your answer
We strongly suggest that you have an outside therapist or coach so you can continue your integration work after the retreat. Are you currently in therapy or working with a coach or mentor? Or do you intend to be?
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Yes
No
If yes, who are you seeing for psychotherapy or coaching?
Your answer
What problems or struggles are you hoping to work through with KAP?
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Your answer
Explain why you think a retreat setting will be good for you.
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Your answer
What are your biggest current stressors in your life?
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Your answer
Do any of the following apply to you?
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Current suicidality
Current self-harming behavior
Past or current psychotic episodes
Past or current substance abuse
Past or current eating disorder
None of the above
Required
Please explain any of the above items you have checked.
Your answer
Do you consume any substances recreationally? What? How often?
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Your answer
Are you concerned about your substance use?
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Yes
No
Do the following apply (as a past or current diagnosis) to you or close relatives? Select "no" if it is not applicable, or one of the following for each choice: Self, Mother, Father, Sibling(s), Significant Other (Sig Other)
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No
Self
Mother
Father
Sibling(s)
Sig Other
Schizophrenia
Mania
PTSD
Anxiety
Depression
Psychosis
No
Self
Mother
Father
Sibling(s)
Sig Other
Schizophrenia
Mania
PTSD
Anxiety
Depression
Psychosis
Have you had a recent (within the last year) acute psychiatric hospitalization or ER visit? If yes, please explain what it was for.
Your answer
Do you have any health concerns, specifically regarding high blood pressure, heart, liver, bladder issues, sleep apnea, or glaucoma? If yes, please explain.
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Your answer
Have you ever had experiences of non-ordinary or altered states of consciousness? How was the experience for you? This can include breathwork or psychedelic use.
Your answer
Are you currently pregnant or breastfeeding? If yes, please explain which one.
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Your answer
Please tell us a little about what brings you joy! Hobbies, passions?
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Your answer
Do you have any questions for us about KAP?
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Your answer
A copy of your responses will be emailed to the address you provided.
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