KAP Group & Mini-Retreat Pre-Screen
Thank you for submitting your interest in Joy In Health's KAP Mini-Retreat program! Please complete the form below. If you have any questions regarding this application and/or the program in general, you can reach out to us at hello@joyinhealth.com
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Full Name *
Phone Number *
Email address *
How did you hear about us? *
What are the main issues? *
Required
Are you currently working with a therapist? *
Do you have previous experience with altered states of consciousness including psychedelic substances like MDMA, LSD, psilocybin, ayahuasca, or ketamine? What was your experience like?
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Do you have a history of psychosis or have you experienced psychotic or manic symptoms while under the influence of a drug or medicine or while having a meditative experience?
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Are you aware of a family member who has or has had a diagnosis of schizophrenia or another psychotic disorder?
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Do you have any medical issues? If yes, can you please share them with us to make sure ketamine isn't contraindicated?
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Please share any information that you feel could be relevant
Are there any times that would NOT work for scheduling an appointment?
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Joy In Health PLLC does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible.
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