Rocky Mountain Mind and Body Group Retreat form

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

  • Format: (000) 000-0000.
  • Date of Birth*
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  • Our group Ketamine therapy events are designed as personal growth experiences and are medically/psychiatrically supervised and medically led by Steve Gittelman, PMHNP,CRNA our double board certified Psychiatric Mental Health Nurse Practitioner, and Certified Registered Nurse Anesthesiologist and his team of Registered Nurses. The event is led by Sara Whaley, Director of Patient Care, American Society of Ketamine Providers (ASkP) expert falcuty and Certified Psychedelic Guide along with her team of trauma informed Certified Psychedelic Guides.

    These group therapy events 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.

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

  • Cardiovascular disease, including angina or heart attack?*
  • Untreated high blood pressure?*
  • Stokes or TIA?*
  • Glaucoma?*
  • Seizure disorder (epilepsy)?*
  • Are you currently pregnant?*
  • Have you ever been diagnosed with PTSD or do you suffer from trauma?*
  • Are you currently or in the past under the care of a therapist or psychiatric provider?
  • Have you ever been prescribed Ketamine or taken Ketamine recreationally?*
  • Have you ever had a severe, adverse reaction to using cann@bis, Ketamine, or other psychedelic medicines, physically, emotionally, or otherwise?*
  • Have you ever required significant treatment or been hospitalized for a psychological or emotional reason?*
  • Do you have any allergies or had a severe, adverse reaction to any other substances or other medicines?*
  • Has a health professional ever advised you to cease or otherwise limit consumption of alcohol, cann@bs, Ketamine, psychedelic medicines?*
  • Have you ever experienced extreme paranoia or anxiety, panic attacks, or other extreme negative experiences while using any psychedelic substances, Ketamine, or any other substance?*
  • Do you have any present concerns around suicide or self-harm?*
  • Do you have any acute, current or past substance abuse/dependence issues?*
  • Do you ever feel extremely uncomfortable in group settings?*

  • 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.

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