Rocky Mountain Mind and Body Group Retreat form

Thank you for your interest in our group Ketamine therapy retreat. Please complete all of the information below as Step 1 of your application process.
First Name*
Last Name*
Phone Number*
Please enter phone number
Date of Birth*

MonthDayYear
Email*

Confirmation EmailPlease confirm email
Group Ketamine Retreat Interest. Please tell us why you are interested in joining our group therapy event*

Please write a sentence or 2 describing your interest in this event0/100
Our group Ketamine therapy retreats are designed as personal growth experiences and are medically led by Steve Gittelman our double board certified Psychiatric Mental Health Nurse Practitioner, and Certified Registered Nurse Anesthesiologist and his team of Registered Nurses. The retreat is led by Sara Palecki, Director of Patient Care, Natural Medicine licensed Facilitor and Certified Psychedelic Guide along with her team of Certified Psychedelic Guides.

These retreats are not appropriate for pregnant women or for people with untreated cardiovascular problems, severe hypertension, recent history of Hemorrhagic stroke, or severe mental health diagnoses.

We do require a thorough medical/psychiatric assessment and clearance for all attendees. All cleared participants are also required to attend the preparation appointment prior to attending any group therapy event.

This form is HIPAA compliant and all answers to the following questions are to assist the medical director and retreat facilitators and will be kept strictly confidential. Please answer as completely as possible to be considered.

Consent and Agreements
By completing this form, you acknowledge that the information provided is true and accurate to the best of your knowledge. You understand that the information shared is confidential and will not be shared with any third parties without your consent, except as required by law. You also understand that Rocky Mountain Mind and Body LLC, 750 W Hampden Ave suite 215, Englewood CO 8110 does not provide medical advice or treatment advice for group therapy events and are aware that emotional issues may be evoked during a group therapy event. You understand that it is your responsibility to seek out professional emotional support if needed such as follow up pscyhotherapy. Your participation in the group therapy retreat is purely voluntary, and you elect to participate if your application is accepted in spite of the above-mentioned risks.

Rocky Mountain Mind and Body LLC does not sell, provide, supply, manufacture, cultivate, transport, or distribute any controlled substances. All medicine used during the group therapy is prescribed to the individual participant and is not to be used by any other person other than the medically cleared group participant. Rocky Mountain Mind and Body LLC does not engage in, endorse, or facilitate the use of any unlawful conduct or the use of any substance other than the lawful use medicinal Ketamine as regulated by the DEA.

All information gathered via this form is HIPAA compliant and is strictly confidential and only used to medically pre-screen potential group Ketamine group therapy participants as the first step of overall clearance to attend.
Please verify that you are human*
Should be Empty:

Thank you for your interest in our group Ketamine therapy retreat. Please complete all of the information below as Step 1 of your application process.

Do you have any history or currently suffer from any of the following:

Consent and Agreements