Pre-Registration Form
This form will be kept confidential and only used for the purposes of assessing your eligibility for the retreat and assist with preparing for your medical assessment.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
OHIP #
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Are you currently/recently employed providing healthcare services?
*
No
Yes (please specify the nature of your job)
Do you have a pre-existing personal or professional relationship with one the the facilitators.
*
No
Yes
Please specify which facilitators (select all that apply). If you have a pre-existing relationship with one of the medical facilitators, your medical assessment will be completed by a different facilitator.
Maggie Pajak
Mary Foran
Jared Dalton
Dr. Cheryl Willsie
Dr. Anthony Giordano
Could you please describe the nature of this relationship? (Ex. Existing patient/client or friend/colleague)
Do you have access to a Family Doctor or Nurse Practitioner?
*
No
Yes (please provide their name/phone/fax number)
If so, do you consent for us to request a referral and a summary of relevant portions of your medical record (including a list of medical conditions, medications, allergies and any consultation reports completed by a psychiatrist)?
*
No
Yes
Are you currently receiving regular or ongoing treatment/therapy from a psychiatrist?
*
No
Yes (please include their contact information here)
If so, do you consent for us to contact them to ensure this retreat is compatible with your ongoing care plan?
*
No
Yes
Do you have extended health benefits that provide reimbursement for professional services provided by a Registered Social Worker (MSW RSW)? If so, we will provide you with a receipt that may enable you to receive reimbursement for some of the fees associated with the retreat.
*
No
Yes
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Help us understand a little more about your medical history.
Please note that we take the personal nature of these questions very seriously and we will use this information in good faith to make sure the retreat will be a safe and positive experience for everyone. Some medical or psychological conditions make group therapy with ketamine unsafe, and other medical conditions can be accommodated with appropriate preparation, so please support us by answering these questions as completely as you can. The facilitator team will be working together collaboratively to ensure your safety. This would usually involve sharing relevant information between facilitators about our participants as we prepare for the retreat and during the retreat. If there is any information you would not be comfortable being shared with other facilitators please let us know during the medical intake process. No information about your personal health or psychological history will be shared with other participants.
Are you under active treatment for any medical condition, or have you been diagnosed with a medical condition that required long term treatment or hospitalization?
*
No
Yes
Please list these conditions here:
Do you take any regular medications (prescription or over the counter)?
*
No
Yes
Please list these medications here:
Do you have any allergies to medications?
*
No
Yes
Please list your medication allergies:
Have you used ketamine in the past?
*
No
Yes
If so, please briefly outline how recently and the nature of the use as well as any reactions (positive or negative) you may have had.
Have you ever had an issue with addiction or the inability to control your use of any particular substance?
*
No
Yes
If so, please provide a brief outline of when this was an issue for you, whether this is ongoing and whether you received or are receiving treatment for this.
Are you currently using any recreational drugs/substances/alcohol?
*
No
Yes
If so, please identify the substance, how often you use it and how much you use in a typical week
Are you pregnant or nursing? Or is there a possibility of becoming pregnant?
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No
Yes
Do you have high blood pressure or hypertension? If so, are you receiving treatment for this, and is it considered controlled?
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No
Yes. Receiving treatment and controlled.
Yes. Receiving treatment but uncontrolled.
Yes. Not receiving treatment.
Have you been diagnosed with hyperthyroidism?
*
No
Yes
Do you experience obstructive sleep apnea or use a CPAP/BiPAP machine? Do you stop breathing in your sleep?
*
No
Yes. I do NOT stop breathing during sleep.
Yes. I stop breathing during sleep.
Do you suffer from heart disease or chest pains?
*
No
Yes
Do you suffer from lung or respiratory disease?
*
No
Yes
Do you have epilepsy or have you experienced seizures?
*
No
Yes
Have you had a serious head injury in the last year?
*
No
Yes
Have you ever had a heart attack or stroke?
*
No
Yes
Do you have any other concerns relating to your physical health we didn’t ask about above?
*
No
Yes
If so, please provide further details regarding any concerns you have about your physical health.
Have you previously been diagnosed with or treated for any of the following mental health concerns:
*
Depression
Anxiety
PTSD
Bipolar Disorder or Cyclothymia
Schizophrenia or Psychosis
Borderline or Other Personality Disorder
None
Other (Please Specify)
Have you ever been admitted to hospital for a mental health condition?
*
No
Yes
Please provide a brief history of any prior mental health diagnoses, treatment or hospitalizations.
How would you describe your current mental health?
*
Please provide a brief summary of your current mental health status.
Have you ever experienced a major traumatic event or circumstance in your life, including in childhood, either physical or psychological, either active or passive (e.g. neglect)?
*
No
Yes
Please let us know the general nature of this. There is no need to share specific details.
Have you ever experienced group therapy or worked closely in a group?
*
No
Yes
How was this experience for you?
Have you received counselling in the past, or are you currently seeing a counsellor?
*
No
Yes
Have you had previous experiences with non-ordinary states of consciousness or psychedelics?
*
No
Yes
Please provide a brief outline of those experiences.
Briefly outline any past experiences with non-ordinary states of consciousness/psychedelics (including medicine used, route of administration, and dosage amount if you are able to recall).
Do you have personal support practices/self care routines/supportive relationships that could help you with the integration of anything that comes up during the retreat?
*
No
Yes
Are there any particular questions or concerns you would like addressed during your assessment, or is there anything you think we should know about you that we haven’t asked about? Please provide any details or questions here:
I hereby certify that, to the best of my knowledge, the information provided above is accurate and complete. In the interest of my safety and wellbeing I agree to inform the organizers of any changes to my health status prior to or during the retreat.
Submit
Submit
Should be Empty: