The Intensive Reset - Initial Application

The Intensive Reset - Initial Application

We're so glad you're here. This application is the first step in your journey toward personal transformation and growth. We encourage you to share as much information as you feel comfortable with so that we can truly understand your needs and goals.

Our Intensive Reset program is designed to enhance your sense of self through expanded consciousness and deep self-exploration. By working closely together, we aim to provide a life-changing experience that aligns with your personal growth journey. Your openness, authenticity, and intentionality will be key as we guide you through this powerful process.

Thank you for trusting us with this important step. We're excited to partner with you!
Your Name*

First NameLast Name
Pronouns
(she/her, he/him, they/them, etc.)
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear of us?*
If other, how did you hear of us?
Preferred Reset Location*

Ann Arbor, MichiganPlymouth, MichiganNorthville, MichiganVirtual, Online
Goals
What brings you to explore an Intensive Therapeutic Reset at this time?*
Feel free to share any personal, emotional, or life challenges you’re facing.
What would you like to achieve or work through for this Intensive Reset?*
Have you had previous experience with therapy or personal growth programs? If yes, please provide a brief overview.*
What are your current mental health concerns, if any?*
This may include anxiety, depression, trauma, stress, relationship issues, etc.
Support System

Our Intensive Reset involves deep self-exploration and experiential therapies that may bring up difficult emotions.
Do you have a support system in place (friends, family, or professionals) to help you integrate after the experience? If yes, please describe your support network.*
Health and Safety
Are you currently in crisis or experiencing acute mental health challenges?*

NoYes
If yes, please explain, and note that we may refer you to other resources for more immediate care.
Interest in Optional Ketamine-Assisted Psychotherapy Component
Are you interested in participating in the optional Ketamine-Assisted Psychotherapy component of the Intensive Reset?*

YesNoMaybe
If yes or maybe, what do you hope to achieve through this experiential?
Do you have any medical conditions or take medications that may contraindicate the use of Ketamine? If yes, please describe.
Exclusionary Conditions Would Include: Active substance abuse (Alcohol, cannabis, non-prescribed medications, etc.), History of psychosis, History of increased intracranial pressure, Pregnancy (current), Uncontrolled hypertension, Acute or unstable cardiovascular disease, Previous negative response to ketamine2
Have you had any previous experience with psychedelic-assisted therapies, including Ketamine? If yes, please share your experience.
Self-Pay Disclaimer and Consent
Our Intensive Therapeutic Reset is a self-pay service and is not covered by insurance. By submitting this application, you acknowledge that you are responsible for covering the costs of the program out-of-pocket. (Exception for medical fees related to the optional ketamine-assisted psychotherapy component.)*

I understand that this program is self-pay and will not be billed through insurance
Readiness
This program requires full participation, commitment, and transparency to achieve optimal outcomes. Do you feel ready and willing to engage in this journey with authenticity and intention?*

Yes, I'm ready
Should be Empty:

Goals

Support System

Health and Safety

Interest in Optional Ketamine-Assisted Psychotherapy Component

Self-Pay Disclaimer and Consent

Readiness