Ketamine Assisted IFS Therapy Group - Thursday May 11th, 12:30-3:30pm

Before completing this form, check to make sure room is available, below.

Welcome to a very unique personal growth group experience. We want to make the most of our time together. To help us support you before and during your ketamine journey, please fill out the following as completely as possible. This information is confidential.

After filling out this form and securing your spot in the program with payment for your medical screening ($450) you'll be confirmed as "registered" and have a phone conversation with Keith. We will then schedule you for a 30 minute medical screening with Dr. Vando. Following a successful medical screening you will be "accepted" to the IFS-KAP group. On the day of your KAP meeting your credit card will be charged a second time, for $450.

LOCATION: 8120 Woodmont Avenue, Suite 205, Bethesda, MD, 20814

DATES:

Thursday May 11th, 2023: 12:30-3:30pm

Date

Name:

Date of Birth (mm/dd/yyyy)

Address: Street/PO Box

City:

State:

Zip/Postal Code:

Cell Phone:

Format: (000) 000-0000.

Email:

example@example.com

Gender:

Preferred gender pronouns

Current Occupation:

Person to alert in the event of a medical emergency:

Address:

Relationship to you:

Phone:

Format: (000) 000-0000.

Family Doctor:

Are you currently seeing a psychiatrist? If yes, please list the name of the psychiatrist:

What was the date of your last consultation with your psychiatrist?

Over the last 6 months, on average, how frequently have you had psychotherapy sessions?

Phone # of your psychiatrist:

Format: (000) 000-0000.

Do you give permission to Calliope Health and Keith Miller Counseling to consult with your psychiatrist about your past and present treatment, only if necessary?

Have you met with a psychotherapist for talk therapy within the last year? If yes, please list the name of your therapist:

What was the date of your last consultation with your psychotherapist?

Phone # of your therapist:

Format: (000) 000-0000.

Do you give permission to Calliope Health and Keith Miller Counseling to consult with your psychotherapist about your past and present treatment, only if necessary?

ALLERGIES

Current Medications-Dose, Frequency, Date Last Taken (please also list any supplements or homeopathic alternatives):

Recreational Drugs Method, Frequency, Total # of Experiences, Last Date Used:

Have you used or consumed any unprescribed medicine in the past 30 days? (If yes, which ones? please list them below)

Medical Illnesses, Current and Past:

Have you been prescribed psychiatric medications in the past (e.g. antidepressants, antipsychotics, mood stabilizers, stimulants, tranquilizers)? If so, list each one with dose and describe their effects.

Have you ever been hospitalized for a psychological difficulty?

Please list dates of psychiatric hospitalizations within the last two years.

Have you ever had feelings or thoughts that you didn't want to live?

Have you attempted suicide?

How would you rate your sleeping habits?

Do you have:

Rows	Yes	No
Difficulty falling asleep?
Awakenings during the night?
Poor or unrefreshing sleep?

Current Weight and Height:

Have you recently lost or gained weight?

Please describe any difficulties you experience with your appetite or eating patterns:

Are you currently experiencing overwhelming saddness, grief, or depression?

Are you currently experiencing anxiety, or panic attacks?

How many days per week do you drink alcohol?

How many drinks per night?

How often do you binge drink (4-5 drinks within a couple hours)?

How often do you use recreational drugs?

Have you ever or do you now have a history of prescription drug dependency or abuse?

Have you ever had a dependency on alcohol or recreational drugs?

Females: Are you or could you be pregnant?

If applicable, what form of birth control do you use?

Are you in menopause?

Has anyone in your family been diagnosed with or treated for the following? Please select all that apply:

Has any family member been treated with a psychiatric medication?

In your own words, what is your goal or the nature of the concern that you wish to address in this IFS-Ketamine group? Feel free to describe this in as much or as little detail as you wish. What kind of supportive resources or skills do you have that will help you process the emotional and spiritual content that may emerge during a ketamine journey?

If you feel it is helpful for us to know, please list with dates any significant trauma you have experienced: violence physical, sexual, emotional; abuse; natural occurrences; etc.

What concerns or fears do parts of you have about using ketamine to assist your healing and emotional-spiritual growth?

Because this program involves administering a controlled substance, please upload a clear photo of the front of your driver's license or official ID.

INFORMED CONSENT TO KETAMINE TREATMENT

I, hereby, understand the following risks and statements;

The risks receiving a ketamine injection may include the following common side effects: nausea/vomiting, dysphoria (unpleasant visions or feelings), short-term elevations in blood pressure and heart rate, increased saliva production, dizziness, blurred vision and changes in motor skills. These common side effects of ketamine are short-lived after the medication is metabolized and the medicines will be available to treat many of these symptoms if necessary. It is possible that ketamine will interact with other medications you may be taking. You must disclose all medications you are taking as well as any substances including alcohol, illegal drugs and legal drugs.

Please give consent below:

Payment for Remote Video Screening with Dr. Leonardo Vando

KAP-IFS Psychiatric-Medical Screening

Ketamine Assisted Group Qualification

$450.00 Quantity

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

By signing below you are declaring that the information you have provided above is true and complete.

Signature

Ketamine Assisted IFS Therapy Group - Thursday May 11th, 12:30-3:30pm

Confidential Information

Payment for Remote Video Screening with Dr. Leonardo Vando*

Payment for Remote Video Screening with Dr. Leonardo Vando