Application for IFS-Ketamine Couples Group

This class will facilitate personal growth and emotional development by using ketamine in conjuection with educational group processing. It is not psychotherapy, nor is it intended to replace psychotherapy or health care. The exercises you will do in this class may touch deep places inside you that can cause psychological, emotional, physical, or behavioral reactions. For some people, these reactions may be hard to deal with.

IFS is a very safe and respectful form of inner work, but for a few people this class may not provide the kind of individual attention and structure needed to feel balanced and safe while working on deep personal issues.

This survey is designed to help us discern together gow you will have the best experience in this class and give me a sense that you've made an informed decision and are ready for this work. If you would like to discuss whether the class is safe for you, feel free to email or call Keith at keith@keithmillercounseling.com or 202-629-1949 ext 2.

The information shared on this form will not be viewed by anyone other than Keith Miller and is confidential. Your answers will not be shared with your partner or with anyone in this group.

DATES:

Fri, June 16, 7-9pm, Zoom Introduction and onboarding
Sat, June 17, 12-3pm, Ketamine experience
Thurs, June 29, 7-9pm, Zoom integration group

Sat, July 15, 12-3pm, Ketamine experience
Thurs, July 27, 7-9pm, Zoom integration group

Sat, August 12, 12-3pm, Ketamine experience
Thurs, August 24, 7-9pm, Zoom integration group

Sat, September 9, 12-3pm, Ketamine experience
Thurs, September 21, 7-9pm, Zoom integration group

Name*

First NameLast Name

Partner's Name (each partner must fill out a separate application form):*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What experiences have you had with Internal Family Systems Therapy? (i.e. IFS therapy, attendance at an IFS workshop or training or educational materials) *

Describe a typical conflict pattern between you and your partner that you would like to change. If possible, name which protective part of you reacts most strongly for you and why its difficult for you to get this part of you to step aside during conflict. (None of the information on this form will be shared with anyone else in the group or with your partner...100% confidential).

What psychological issues are you facing now or what parts of you would you like to work on? *

How much and how frequently do you currently use drugs and alcohol?*

Do you have any history of emotional instability? Please explain.*

YesNo

If you experienced emotional difficulty or felt like you were falling apart, what steps would you take to regain stability?*

Are you currently in psychotherapy? For how long?*

I understand the IFS-Ketamine Assisted Group Experience taught by Keith Miller is not psychotherapy or health care and is not intended to replace psychotherapy or health care.

I understand that even though the course content teaches concepts frequently used in psychotherapy, the exercises are intended to teach me skills for my personal growth. Exercises may involve accessing sensitive psychological material, and I declare that I have the psychological stability to handle whatever may come up.

I am responsible for my participation in the class and any psychological work that I choose to do, and I will not hold Keith Miller or Keith Miller Counseling, LLC responsible for any pain or damages that may occur.

NEXT STEPS: **Make sure your partner also fills out their own application form** Within 48 hours after receiving BOTH partner's forms you'll receive an email or call from me to schedule a 30 minute call. After our call, if we decide you and your partner are a good fit for this group, I'll send you an enrollment link where payment for the first of four installments due.

COST:

Early Registration (prior to June 1st): Cost per couple is $750 per month, for four months, ($3000 total). This includes a medical screening with Dr. Leonardo Vando.

Standard Registration (after June 1st): $770 per month, per couple, each month for four months.

Refunds: Prior to June 7th a refund, less $500, will be given. After June 7th, there are no refunds.

Payment of the full amount (all four sessions) is expected even in the event that you cannot attend one of the dates. Payments may be made once per month or you may pay in full.

This is amazing work and a very unique experience, and I look forward to meeting you soon!

Keith

Signature: Please type your full name*

IFS-Ketamine Couples Group

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