September 14-15 K-IFS Couples Retreat Retreat

DATES:

Friday, September 13, 2024: 6-8pm, Zoom
Saturday, September 14, 8:45am - 3pm
Sunday, September 15, 9am-3pm
Friday, September 20, 4-6pm, Zoom

This retreat will facilitate personal growth and emotional development by using ketamine in conjunction with educational teaching and group processing. It is not psychotherapy, nor is it intended to replace psychotherapy, couples therapy, or health care. The exercises you will do in this class and the effects of receiving a ketamine injection 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 retreat 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 if joining the retreat will be benificial to you. If we decide you will participate, your answers below will guide me to know how you will have the best experience in this retreat and give me a sense that you've made an informed decision and are ready for this work.

It is expected that strong emotional content may be shared by other group members during the retreat. This can trigger an emotional reaction in you. The retreat is not designed to provide extended individual/private support to you. Rather, the group itself will act as a container for our individual responses, to help us regulate ourselves and stay in sync with both our inner experience and the experiences of others around us.

Upon receipt of your answers, below, I will schedule a 15-minute zoom call to discuss your application.

If you are admitted into the retreat you'll be sent a payment link prior to scheduling your health screening.

Date:*

Date of birth:*

Name:*

Partner's Name: (must apply at the same time, separately)*

Address: Street/PO Box*

City:*

State:*

Zip/Postal Code:*

Cell Phone:*

Email:*

example@example.com

Gender:*

Preferred gender pronouns

Education Background (grade/degree completed, any post secondary):

Current Occupation:*

Person to alert in the event of a medical emergency:*

Address:*

Relationship to you:*

Phone:*

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:

If needed, do you give permission to Keith Miller, Calliope Health and Keith Miller Counseling to consult with your psychiatrist or medical doctor about your past and present health and treatment?*

YesNo

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:

If needed, do you give permission to Keith Miller, Calliope Health and Keith Miller Counseling to consult with your psychotherapist about your past and present treatment?*

YesNo

Relationship Status:*

Spouse's/partners name:

Phone

Children (gender, age)*

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:*

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?*

YesNo

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?*

YesNo

Have you attempted suicide?*

YesNo

How would you rate your sleeping habits?*

Do you have:*

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

Current Weight and Height:*

Have you recently lost or gained weight?*

YesNo

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

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

YesNo

Are you currently experiencing anxiety, or panic attacks?*

YesNo

How many days per week do you drink alcohol?*

How many drinks per day?*

How often do you binge drink (4-5 drinks within 2 hours)?*

How often do you use recreational drugs?*

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

YesNo

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

YesNo

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?*

YesNo

Please list any problems you or a relative have had with anesthesia:*

In your own words, what is the nature of the concern that you wish to address by participating in this K-IFS retreat for couples? 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 and our group experiences? *

Describe the most typical pattern of conflict in your relationship. What happens? What do you do/say? How does your partner respond? What happens next? Describe who you are in conflict, that is, how do you protect yourself and deal with your emotions when you've experienced a disconnect with your partner? *

Describe your experience(s) with couples therapy and how these have been helpful/unhelpful.*

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? *

Please detail why you feel that participating in this retreat will benefit you and explain how you are prepared engage supportive practices during and after the retreat.*

IFS Two-Day Ketamine-Assisted Retreat for Couples - Sept 2024

Confidential Information