Healers Group KAP - Application & Interest Form

Thank you for taking the time to express your interest in the Healers Group KAP. 

This group was created with you in mind. Whether you're a licensed clinician, a pre-licensed practitioner, a somatic therapist, an energy worker, a Reiki practitioner, or anyone whose purpose is rooted in the healing of others, this is a space built for the people who hold space for everyone else.

This group is capped at 6 participants, so it will be small, intentional, and deeply supported. All sessions are held virtually, so you can show up from wherever feels most comfortable to you.

This form serves two purposes: to give you the information you need to make a decision about joining, and to help us get to know you before we connect. It should take no more than 10 minutes to complete.

Not ready to commit to this round but still interested? Please complete this form anyway. We'll keep you in the loop on future offerings.

Before joining, three things are required: 
1. You MUST be a Tennessee Resident.
2. A one-on-two consultation with both of the group facilitators. 
3. A medical consultation with Journey Clinical's prescriber to obtain your ketamine prescription.
All of these happen during the preparation phase, before the group begins. 

Your Facilitators:
Musenge Luchembe, LMFT, LPC-MHSP (she/her) | @musengetherapy | www.musenge.com
Tozia Ware, A-LPC-MHSP (he/him) | @modernblacktherapist | www.modernhealingco.com

Resources:
Ketamine-Assisted Psychotherapy (KAP): How It Works and What to Expect at Journey Clinical
Ketamine & Neuroplasticity: Long-Term Brain Effects
Ketamine Treatment Options: Understanding the Differences

Sign in to Google to save your progress. Learn more
Email Address *
What is your First and Last name? 

Please include a preferred name and pronunciation guide if helpful, for example "TAH-zah" 
 *
What pronouns do you use? *
What is the best phone number to reach you? *
How do you identify as a healer? What is your current role or practice?

For example: licensed therapist, somatic practitioner, energy worker, Reiki practitioner, pre-licensed clinician, etc. *
What, if anything, would you like to share about your other identities or lived experiences? (race, gender identity, neurodivergence, disability, etc.)
Why are you interested in this Healers Group KAP? What do you hope to gain from this community offering? *
Financial Investment
This group is priced to be as accessible as possible without compromising on care. The total investment for the group is $2,495. This breaks down into two parts: fees paid to your facilitators for therapeutic support, and one-time medical fees paid directly to Journey Clinical for your medical evaluation and medication.

FACILITATOR FEES — $1,775
This covers all of your therapeutic support with your facilitators, including your individual intake session, 2 group preparation sessions, 6 ketamine dosing sessions, and the integration sessions that follow. It is paid in three installments:
• $500 non-refundable deposit — reserves your spot and is applied toward your total
• $637.50 — due at the start of the group
• $637.50 — due at the midpoint of the group

JOURNEY CLINICAL — $720
Paid directly to Journey Clinical as one-time, upfront payments for your medical care and medication:
• Medical initial consultation — $250
• Two initial doses — $112
• Medical follow-up consultation — $150
• Additional six doses — $208

Your individual intake with a facilitator is included in the facilitator fee above. Journey Clinical fees are billed and paid separately, directly to Journey Clinical.

For your reference: To receive ketamine infusions alone (without therapy), IV or intramuscular sessions typically cost around $400 or more each — so 6 infusions would run about $2,400 and up, with no therapeutic support included.

For $2,495, our group model includes 2 preparation sessions, 6 ketamine dosing sessions, and integration sessions with full therapeutic support, and this cost also covers the medication, the medical consultations, and your individual intake session. 
Having reviewed the financial investment above, are you able to commit to the full cost of the group? *
Scheduling & Availability
This group runs for 7 flexible weeks, in addition to your individual intake session and medical consultation with Journey Clinical during the preparation phase. All sessions are held virtually, and this group is open to Tennessee residents only.

We don't have exact calendar dates yet, but our sessions fall on the following days of the week. Please plan to block off these days:
• 2 Preparation sessions — Fridays and Sundays - 9am - 10:30am CST (90 mins)
• 6 Ketamine dosing sessions — Fridays and Sundays - 9am - 12pm CST (3 hours)
• 3 Integration sessions  — Fridays - 9am - 10:30am CST (90 mins)

Because this is a small, intimate group, it is vital that members are able to attend all sessions. Exact dates and times will be confirmed with you during your screening call.
Having reviewed the schedule above, are you able to commit to the full length of the group and block off these days of the week? *
Do you have any questions for the group facilitators?
Completing this application does not automatically qualify you for group. All group members must be cleared by both facilitators and Journey Clinical's medical team in order to participate.

Do you understand that you must complete an individual medical consultation with Journey Clinical for your Ketamine prescription and have an individual intake with the the group facilitators in order to participate? 
 *
Schedule Your Intake Session
If the schedule works for you and the financial investment feels right, the next step is to schedule a call with the facilitators. This individual intake conversation is a required part of the preparation phase and a chance for us to connect, answer your questions, and confirm that this group is a good fit before we move forward together.


Please note: This scheduling link is only available here within the form and will not be shown after you press Submit. Be sure to click the link and book your call, or save the link somewhere safe, before submitting this form.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Modern Healing Collective PLLC.

Does this form look suspicious? Report

Google Forms