Jamaica Retreat Application
JANUARY 5-8, 2023
First Name
*
Last Name
*
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Email address
*
example@example.com
Cell phone
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
Sex (assigned at birth)
*
Please Select
Female
Male
Other
Prefer not to answer
Race
*
Please Select
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
A race not listed here
Prefer not to answer
Preferred pronoun(s)
*
She / her / hers
He / him / his
They / them / theirs
Xe / xem / xyr
Please just use my name
Other
Gender (at birth)
*
Male
Female
Non-binary / non-conforming
Transgender
Other
Prefer not to say
Job Role/Title
Employer
Years employed
Hours per week
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Psychiatric History
Have you received a previous psychiatric diagnosis?
*
Yes
No
If yes, please list the details (including date of onset)
Have you had thoughts of suicide?
*
Yes
No
Have you ever experienced auditory or visual hallucinations?
*
Yes
No
Have you ever received psychiatric treatment for depression? (Medication(s), therapy, inpatient hospitalization, electroconvulsive therapy (ECT), etc
*
Yes
No
Please list the details of your psychiatric treatment for depression.
Do you use tobacco?
*
Yes
No
If you answered YES, please describe your tobacco use.
Do you drink alcohol?
*
Yes
No
If you answered YES, approximate number of drinks per week.
Have you ever been treated for addiction to alcohol or any other substance?
*
Yes
No
Do you use recreational drugs?
*
Yes
No
If you answered YES, which recreational drugs do you use?
Cocaine
Amphetamines
LSD
Psilocybin
Marijuana
Heroin/PCP
Ecstasy/MDMA
Other
Previous Psychiatric Medications (please mark if you have taken any of the following)
*
Antidepressants
Anxiolytics
Antipsychotics
Anticonvulsants/mood stabilizers
Alcohol antagonist
Benzodiazepine
CNS depressant
Dopamine agonist
NMDA receptor antagonist (i.e., ketamine)
MAOI
Marijuana
Opiate antagonist
Sedative
Stimulants
Triptans
Opiates
Unknown
None of these
Other (something not listed)
List previous psychiatric medications (name, dose, and duration they were taken)
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Medical History
Have you had brain surgery, tumors, or blood vessel malformations in the past?
*
Yes
No
Do you have glaucoma?
*
Yes
No
Have you had a recent eye injury or surgery?
*
Eye injury
Eye surgery
None of the above
Do you have a history of hyperthyroidism or hypothyroidism
*
Yes, hyperthyroidism
Yes, hypothyroidism
No
Do you have a history of high blood pressure
*
Yes
No
If taking blood pressure medications, list them here.
Do you have a history of cardiac problems? (Previous heart attack, heart arrhythmia, heart murmurs or defects, etc.)
*
Yes
No
Do you have a history of seizures?
*
Yes
No
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Current Medications and Conditions
Are you currently taking any narcotic (opiate) pain medications?
*
Yes
No
Are you currently taking benzodiazepines, mood stabilizers, or monoamine oxidase inhibitors (MAOIs)?
*
Yes
No
Are you currently pregnant, breastfeeding, or planning on becoming pregnant in the near future?
*
Pregnant
Breastfeeding
Planning on becoming pregnant in the near future
None of the above
Current psychiatric medications (please mark if you are taking any of the following)
Antidepressants
Anxiolytics
Antipsychotics
Anticonvulsants/mood stabilizers
Alcohol antagonist
Benzodiazepine
CNS depressant
Dopamine agonist
NMDA receptor antagonist (i.e., ketamine)
MAOI
Marijuana
Opiate antagonist
Sedative
Stimulants
Triptans
Opiates
Other
Unknown
List all current medications (name and dose)
List any other medical conditions not noted above and/or provide explanations of the conditions mentioned above that you feel would be helpful for us to know.
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