Language
English (US)
Español (Argentina)
Name
*
First Name
Last Initial
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Medicine Session
*
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Session number
Integration 1
Integration 2
Integration 3
Integration 4
Integration 5
Integration 6
Booster Integration
Other
Client type
*
Michael DeMarco, PhD
KAP Clinician Training
Other
Medicine
ketamine
Other
Route of administration
iv
injection
nasal
sublingual / by mouth
suppository
Other
Choose which type of experiences you felt during your treatment. Choose any that apply.
EMPATHOGENIC EXPERIENCE Awareness of body; comfort and relaxation; reduced ego defenses; empathy, compassion, and warmth; love and peace; euphoria; mind is dreamy with non-specific colorful visual effects
OUT-OF-BODY EXPERIENCE (OBE) Complete separation from one’s body; significantly diminished ego defenses; visits to mythological realms of consciousness; encounters with non-terrestrial beings; emotionally intense visions (e.g., deceased relatives, spirits); vivid dreams of past and future incarnations; re-experiencing the birth process
NEAR-DEATH EXPERIENCE (NDE) Departure from one’s body; complete ego dissolution/loss of identity; experienced physical (body) and psychological (mind) death; experience being a single point of consciousness simply aware of itself; reliving one’s life aware of how actions have affected others, with moral judgment of self
EGO-DISSOLVING TRANSCENDENTAL EXPERIENCE (EDT) Ecstatic state of the dissolution of boundaries between the self and external reality; complete dissolution of one’s body and self (soul); transcending normal mass/time/space continuum; collective consciousness; unity with Nature/Universe; sacredness
I did not have any of these experiences
How did the preparation and/or integration session/s affect this experience?
What did you feel during this experience that you would like to feel again?
What was your intention before taking the medicine? How did your experience reflect your intention?
What was the most negative or difficult part of your experience?
What were you able to remember, carry forward, and/or complete that you had intended in your treatment?
What visions or information were you able to bring home to your community about your medicine work?
Describe what, if anything, has been different for you post-ketamine in terms of your mental health.
How have you manifested your visions or experience on the physical plane? In your life? Work? Relationships? What could you improve upon?
How did your experience affect your identity? Who is the person you want to become in your life and how can this experience contribute to your growth and expansion?
What are your intentions in life and how did this experience contribute to your larger goals and desires?
What was the most positive part of this experience?
Describe what kind of effect the music had on your experience.
Choose any of the following that may describe your medicine journey as best you understand. Choose any/all that may feel important in conveying a sense of your felt experience.
INTERNAL UNITY- described as awareness of all normal sense impressions (visual,auditory,touch, smell, taste, and/or movement) ceases, and the empirical ego (i.e., the usual sense of individuality) seems to die or fade away while pure consciousness of what is being experienced paradoxically remains and seems to expand as a vast inner world is encountered. A sense of movement is experienced within this inner world through numerous so-called "dimensions of being" towards a goal that is felt to have the status of ultimate reality. Internal unity occurs when consciousness merges with this "ground of being," beyond all empirical distinctions. Although awareness of one's empirical ego has ceased, one does not become unconscious.
EXTERNAL UNITY- described as awareness of one or more particular sense impressions grows in intensity until suddenly the object of perception and the empirical ego simultaneously seem to cease to exist as separate entities, while consciousness seems to transcend subject and object and become impregnated by a profound sense of unity, accompanied by the insight that ultimately "all is One." The subject-object dichotomy transcended may be between the empirical ego and an animate visual object such as another person or a rose; an inanimate visual object such as the leg of a table or even a grain of sand; or an auditory object such as the music of a symphony.
OBJECTIVITY AND REALITY- described as insightful knowledge or illumination about being or existence in general that is felt at an intuitive, nonrational level and gained by direct experience, and the authoritativeness or the certainty for the experiencer that such knowledge is truly or ultimately real, in contrast to the feeling that the experience is a subjective delusion. These two elements are connected because the knowledge through participation in ultimate reality (in the sense of being able to know and see what is real), carries its own sense of certainty
TRANSCENDENCE OF SPACE/TIME- described as the loss of a person's usual orientation as to where he is during the experience in terms of the usual three-dimensional perception of his environment, and on the other hand, to a radical change in perspective in which you suddenly feel as though you are outside of time, in eternity or infinity, beyond both past and future. In this state of consciousness, space and time are generally meaningless concepts, although one may feel that one can look back on the totality of history from this transcendent perspective.
SENSE OF SACREDNESS- described as a nonrational, intuitive, hushed, palpitant response in the presence of inspiring realities. It is that which a person feels to be of special value and capable of being profaned. Inherent in the nondifferentiated unity of mystical consciousness is a profound sense of holiness and sacredness that is felt to be at a more basic level than any religious or philosophical concepts held by the experiencer, an acute awareness of finitude may be experiences, as though one had stood before the Infinite in profound humility, overwhelmed by feelings of awe and reverence.
DEEPLY-FELT POSITIVE MOOD- described as the feelings of joy, love, blessedness, and peace. Joy may be exuberant or quiet. Love may vary in intensity from feelings of tenderness, through deeply-felt nonsensual feelings of ultimate concern for other persons, to a state resembling prolonged intense sexual orgasm. The latter degree of intensity is generally dissociated from any stimulation or excitation of the sexual organs, being "spiritual" rather than "erotic" in nature. Peace is "the peace which passes understanding" and entails not only deep relaxation, but a conviction that there is no ground for anxiety.
PARADOXICALITY- This category reflects the manner in which significant aspects of mystical consciousness are felt by the experiencer to be true in spite of the fact that they seem to violate all standard logic. This may feel like the experience that you have died or ceased to exist, yet obviously continue to exist, experiencing an empty unity that at the same time contains all reality, an experience of non-being that is more than being, you may have felt "out of the body" while still "in the body", you may envision a universal self that is both unqualitied and qualitied, both impersonal and personal, and both inactive and active.
INEFFABILITY- described as attempts to communicate the experience verbally to another person, that the available linguistic symbols, if not the structure of language itself, are inadequate to contain or even accurately reflect such experience. Such an experience may be felt to be beyond words is to be found in a frustration with language, which, in turn, arises out of the paradoxical nature of the essential phenomena and the incomparable uniqueness of the experience itself.
TRANSIENCY- described as temporary duration of the medicine experience in contrast to the relative permanence of the level of usual experience. The special and unusual forms of consciousness discussed above appear, remain for anywhere from a matter of seconds to a few hours, and then disappear, returning the experiencer to your usual state of everyday consciousness. The characteristic of transiency indicates that the state of consciousness during your experience is not sustained indefinitely and marks one of the important differences between it and psychosis.
POSITIVE CHANGES IN ATTITUDE/BEHAVIOR- described as changes in attitudes (1) toward your self, (2) toward others, (3) toward life, and (4) toward mystical consciousness itself, experience Increased personality integration including a renewed sense of personal worth coupled with a relaxation of habitual mechanisms of ego defense.
VISUAL PHENOMENA- this may be described as visuals like geometric patterns, the room feeling very far away, colors, forms, kaleidoscopic effects, a sense of seeing the music, architecture, unrecognized writing, imagery that may feel related to stories from cultures or religions that may or may not feel familiar to you. Associated with such imagery, you may live through the whole spectrum of human feelings. You may experience a variety of intriguing somatic (bodily) sensations, feeling as though your body is melting, falling apart, or exploding into minute fragments. On occasion sexual pleasure may be experienced, as well as giggling and laughter.
REGRESSING TO CHILDHOOD, OTHER LIFE IN REVIEW- described as an auto-biographical type of experience that may include found memories, or ability to see with new detail into past conflicts, traumas, or time-periods in your life. This may also include a confrontation of guilt.
PSYCHOTIC PHENOMENA- described here as experiences of paranoia, of panic, or of extreme disorientation and confusion, generally occuring when one attempts to control the experience instead of passively yielding to whatever develops. Similarly, panic seems to be associated with an attempt to escape from emerging experiences instead of accepting and confronting them. Also the experience of feeling as though one is separated from the world by a thick, glass wall, being trapped in a silent, unreal room where no activity whatsoever.
COGNITIVE PHENOMENA- described as feeling capable of thinking unusually sharply, quickly, and clearly.
Brilliant White Light, feeling electrical currents
Nausea, Rapid Heartbeat, Stomach contractions, feeling cold/clammy
A sense of having lived through evolutionary processes
A sense of telepathy, clairvoyance
A sense of understanding/being connected to your body processes
Altered perception of time- time passing more quickly or slowly than you had expected
Other
How did you feel supported or not supported by your sober sitter? What can you prepare differently for next time to ensure you feel best supported?
How did this experience compare to any past psychedelic experiences with other medicines?
Self-Actualization = Big Self Energy : Check off any you find yourself feeling more often than not since your medicine journey
Calm
Curious
Connected
Compassionate
Courageous
Confident
Clarity
Creativity
Was this medicine journey right for you?
I found ketamine therapy helpful
I did not find ketamine therapy helpful
Thinking over the past week, how would you rate how well you're able to meet your basic personal physiological needs? (These include adequate food, clean water, clean air, restful sleep, moving my body, and personal sexual fulfillment)
Thinking over the past week, how would you rate your sense of safety and security? (These include areas like housing, finances, employment, mental & physical safety & health, and relative freedom from oppression/repression)
Thinking over the past week, how would you rate your accomplishments, personal achievements and growth and your sense that these areas are acknowledged and recognized by others?
Thinking over the past week, how would you rate your ability to feel and express love and belonging with friends, family, intimate relationships, and community?
Over the past week, how would you rate your sense of self-actualization and feeling generally okay in your own skin? (This might mean achieving your full potential in feeling a sense of calm, clarity, confidence, creativity, courage, curiosity, connectedness, compassion).
Total
Over all, where 0 is not enough, and 10 is too much, how would you rate finding Meaning in your life in general right now. Slid to the left, you’re putting meaning on every single thing that happens to you, some of which may actually not matter in the big scheme of things. Slid to the right, maybe you’re not finding enough meaning in your life and nothing feels meaningful or like it matters.
In general, where 0 is not enough, and 10 is too much, how would you rate feeling connected to others in life? Slid to the left, you may feel like a people-pleaser, or like you have to connect to every single person in life, or fear people not liking you. Slid to the right, you may feel completely isolated from others, lacking connection.
Out in the world in your daily life, where 0 is not enough, and 10 is too much, how would you rate feeling free to live your life more or less how you'd like to? Slid to the left, you live your life entirely on your own terms and disregard any possible consequences. Slid all the way to the right, you feel completely oppressed or repressed, and lack any feeling of personal freedom in your life.
Thinking about feeling balanced between enjoying life, and accepting your eventual death, where 0 is you may engage in unhealthy lifestyle decisions and/or avoid the topic of your own death entirely. Slid over to the right, you may be so consumed with the thought of death that you forget to experience some parts of being alive, including the reasonable risks that being fully alive may require.
Total
Are you having any thoughts of harm to self?
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I've thought about ending my life since my last medicine journey
I've planned on ending my life since my medicine journey
I've attempted to end my life since my medicine journey
I have access to lethal means of ending my life
I have no thoughts or plan to end my life or harm myself
If you were ever thinking of ending your life or harming yourself, what might be some ways to cope, people to contact or ways to minimize your access to lethal means of taking your life?
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