intake for KAP Name * First Name Last Name Phone * Country (###) ### #### Email * What services are you interested in? * Group KAP Nov 22, 2025 Group KAP Dec 13, 2025 Individualized Session Other Date of Birth * MM DD YYYY Gender * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name & Phone Number * Will this be your first experience with Ketamine? * Yes No Do you have any health or chronic conditions such as cardiovascular disease (heart problems), hypertension (high blood pressure), history of stroke, epilepsy, other physical conditions or disabilities, etc.? * Yes No If you answered yes to the above question, please specify. If you have any serious allergies to medication or food, in particular, any allergic reactions which have required some kind of medical treatment or intervention, please list them below: If you currently are taking medications, please list them below. If you have any special dietary needs, please specify below. (Dietary needs will be shared with our retreat chefs.) If you are currently taking any supplements (vitamins, herbs, homeopathy, superfoods, etc.), please list them below. Are you pregnant? Yes No Do you have any personal history and/or experience of mental illness or have you been diagnosed with any form of mental illness or personality disorder? If so, list below. * Have you ever sought treatment from a mental health professional? Indicate if it was a psychiatrist, psychologist, social worker, etc. What type of therapy did you receive? * Have you been prescribed psychiatric medication(s) of any kind? (for example antidepressants, anti-psychotics, or anti-anxiety.) What is the amount? Reason for taking the medication? * Please indicate any significant family history of mental illness. Has anyone in your family been diagnosed with schizophrenia or bipolar disorder? * Is there anything else you would like for us to know about your health or any other considerations related to potential participation in this retreat? Please share below: * Thank you!
