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Velez Psychiatric Services and Subtle Winds Presents Around The Fire
January 5th 9am to 5pm (Please Note: This event is Sold Out but feel free to complete this form if you wish to participate in future events!)
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Tell us a little about your self and what brings you to this space
*Please note that our lead practitioners and facilitators will follow up with you to do a deeper and more formal screening and preparation call
What best describes the reason for your interest in joining this group retreat
Self Improvement
Spiritual Work/Ceremony
Physical Wellness and Healing
Emotional/Mental Wellness and Healing
Curiosity
Other
The Why?
If your are considering the option of ketamine assisted therapy with this retreat please review the safety and screening outline below first and then answer the following questions.
What is something that you are hoping to work on or focus on as your intention for this journey.
Do you have any medical conditions or medications that you want us to know about before your formal screening with our provider.
Safety and Screening
Below are potential rule outs and may exclude you for ketamine: 1. Pregnant women or nursing mothers: The effects of ketamine on pregnancy and the fetus are undetermined and it is advisable to protect against pregnancy while exposing yourself to ketamine or in the immediate aftermath of its use. Nursing mothers will need additional assessments and coordination of care before being considered for eligibility. 2. Untreated hypertension and/or History of certain types of unstable heart disease, including but not limited to arrhythmia, congestive heart failure, coronary artery disease. 4. History of a bladder transplant or significant bladder/urinary problems. 5. Untreated sleep apnea or severe sleep apnea where a CPAP is required. 6. Allergy to ketamine or esketamine or adverse reactions to anesthesia. 7. Current or past problems with laryngospasm and throat closing. 8. Concerns for habitual use of ketamine, ketamine analogs, or alcohol/benzodiazepine or other substance use with concerns for serious withdrawals when abstinent (severe tremors, seizures, hallucinations, etc. 9. Body Mass Index (BMI) below 16.5 10. History of psychosis or mania requiring hospitalization or certain other behavioral health concerns 11. Untreated hyperthyroidism and certain immuno-compromised conditions
I have read the above safety and screening guidelines and answered the above questions honestly. Please Sign Here.
Today's Date
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The Journey Begins
The cost of the Retreat is $365. You will receive an email back to set up a time for a introduction call once you have completed this form.
Any other comments or questions that we can address?
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