Screen Form for Group KAP
Thank you for taking the time to complete our initial screening form. We are delighted that you are interested in partaking in this journey with us. This form will help us to get to know you and ensure your safety throughout the process. Please answer all questions as honestly and fully as possible. It is important to note that this form is for screening purposes only, and will be shared between professional staff members on this team only. Google Docs does not meet criteria for HIPPA Compliance, so it is important to us to keep your personal information private. Please contact Trish Sullivant, LCSW (801) 541-9566 or Amy Henderson, LCSW (801) 698-3294 if you would like to discuss further, or need assistance completing this form.
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Email *
Your Email
First and Last Name *
Phone Number *
Date of Birth *
You will need transportation to and from 4505 Wasatch Blvd Suite 330, Salt Lake City, Ut 84124 for 1 medicine journeys. Ideally, it's a safe and supportive friend or family member. Please provide the first and last name of your identified "chaperone," along with their phone number. If you're not able to identify someone, we will discuss options during your screening phone call. 
If there is no one identified yet, please put NA.
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Are you Pregnant? *
Required
Please list any current medical issues
If none, please put NA.
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Please list any current medications or supplements 
If none, please put NA.
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Any significant past medical history? Please include dates where applicable:
If none, please put NA.
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Any past/current psychiatric history? Please include dates where applicable:
If none, please put NA.
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Any past/current psychiatric history? Please include dates where applicable:
If none, please put NA.
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Are you currently under the care of a therapist or other helping professional?
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If yes, please list names and lengths of relationships
If none, please put NA. 
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Are you currently under the care of a psychiatrist or other professional who prescribes medication for you? *
If yes, please list names and lengths of relationships and medications that are currently prescribed. 
If none, please put NA. 
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Medication allergies: 
If none, please put NA.
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Food allergies: 
If none, please put NA.
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Any medical or medication concerns you have about this training?
If none, please put NA.
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Do you tend to be sensitive or insensitive to medications?
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Do you have a prior/current history of any of the following?
Please check all that apply:
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Please explain any positive answers above:
If none selected, please put NA. 
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Do you have prior or current history of the following: Please check all that apply.


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Required
Do you have any 1st degree relatives with this condition(s)? 
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Required
If "Yes" Please expand:
If "No" Please put NA.
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Within the last year, have you experienced or are you experiencing suicidal ideation? Please describe:
If none, please put NA.
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Do you have a significant trauma history?
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How much psychotherapy have you completed? 
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Do you have a history of motion sickness or are you quick to nausea?
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Do you have a history of motion sickness or are you quick to nausea?
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Have you required anti-nausea medication in the past?
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Do you engage in mindfulness or self-care practices? Please describe:
If none, please put NA.
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Prior experience with psychedelics?
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Please share any information you feel is helpful regarding past psychedelic use:
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Do you have prior experience with Ketamine? Please describe: 
If none, put NA:  
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How do you feel about taking ketamine in a group setting? Do you have any concerns?
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Please describe your goals for this experience: 
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Do you have any other question or concerns? 
If none, please put NA.
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