Ketamine Experience - 1/31/2026
Please complete this form to help us determine if this retreat is appropriate for you. If it is, this information will also help us create an experience that matches your own experience and interests. After you complete this form, Jenn or Tina will reach out and discuss the retreat further with you. 
Email *
Please note, the facilitators wish is to increase the safety of all participants by conducting a generalized screening of your fitness to participate in the ketamine experiential. You further understand that we cannot medically or psychologically clear you to participate in the experience. Only your own doctor or other medical doctor can provide you with specific clearance. You agree to update any information provided in this form if your circumstances change prior to the ketamine experiential. You attest that all responses to this screening form are truthful and accurate.  
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Name *
Please share your email address and phone number.  We will reach out to schedule a follow up intake.   *
Date of retreat *
This particular Ketamine Day Retreat is for those in the mental health, wellness, and/or helping professions.  Please share a little about how this relates to you as a provider.   
Rather than providing you with boxes to identify yourself, please share anything you believe would be helpful for us to know about you as an individual (ex. pronouns, orientation, age, interests).  *
Please share what drew you to this experience.  *
(e.g., you are curious to experience ketamine for yourself, a client has asked you about it, you want to try it before referring a client, you are considering getting trained in ketamine-assisted psychotherapy)
Any significant past medical history? Please indicate dates where applicable. 
Do you have any current mental health symptoms that we should be aware of?  Any history of a mental health diagnosis?  
Any history of mental health treatment (psychotherapy or medications)? Are you currently engaged in treatment? If so, please describe.
Ketamine is very helpful in process trauma. While this is not a retreat focused on processing trauma, if you have experienced any trauma, it may come up. Please scale your experience with trauma. 
None - Low ACES score
High - High ACES score
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Have you had previous experience with any of the following medicines? 
For any of the above, please share more about your experience with those substances/medicines, whether it was positive, challenging or neutral. Your sharing helps us to support you in this experience.  
Ketamine creates a non-ordinary state of consciousness. Please share your experience with non-ordinary states of consciousness.  This can include how you feel about the idea of non-ordinary states of consciousness and/or if you regularly experience them through substances/medicine,  meditation, breath work, or other spiritual practice. 
The following short list includes contradictions that would suggest that Ketamine may not be appropriate for you. Please check any that may apply. 
Do you have a history of motion sickness or are you prone to nausea?
Do you have any medication allergies that we should be aware of? 
Do you have any food allergies we should be aware of?
Do you have any dietary restrictions or general food preferences (i.e., likes and dislikes) you would like us to be aware of? 
Are there any scents, smells or aromas that are bothersome or problematic for you? If so, please describe.
Is there anything else you believe would be important for us to know about you?  
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