Application

Online Application

Application Process

As a prerequisite to the training, all participants must complete a reading list to familiarize themselves with the basics of pharmacology, ethics, working with alternative medicines, and contemporary scientific studies that elucidate the foundations supporting KAP. Understanding these foundational principles is essential to the training and puts participants on a shared level.

Please note that your information is saved on our server as you enter it.

Welcome to the KTC Application Process. It is designed to be comprehensive to enable selection of participants who will grow from the training and have it inform their practices. Your responses are held in full confidence.

Eligible Applicants for the Training Only Professionals or those nearing licensure may apply to the Ketamine Training Center program if they hold advanced degrees, a license, or ordinations– in one of the following fields:
- Physician and Psychiatrist - MDS, DOs
- Licensed Professional Clinical Counselor –LPCC
- Marriage and Family Therapist–LMFT
- Licensed Clinical Social Worker (LCSW)
- Registered Nurse– RN
- Nurse Practitioner—FNP, NP
- Naturopathic Doctor– ND
- Ordained Clergy and Commissioned Chaplains
- Physician Assistant–PA
- Clinical and Counseling Psychologist—PhD
- Hospice Staff with appropriate training and credentials–EX. CPE units.
At times, we accept those without these licenses because of their unique experience, interest and contributions to the field.

Confidential Personal and Medical Information It is essential that we be aware of any medical conditions, medications, supplements, life experiences or habits that can influence your experience with KTC. Our interest is in helping you have a safe and beneficial experience. Please fill out the following as completely as possible. This information is confidential.

Saving your work Please note that the application is a bit lengthy. If you are interrupted and would like to save your work so you can finish it at a later time, please scroll down to the bottom of the form where you will see a link next to the submit button to save and continue the form later. If you click this it will save all the work you've done up to that point and give you a custom link you can return to for up to 30 days. You can also request that the custom link be emailed to you once you've clicked on the "save and continue later" link.
Name*
First Last
How did you hear about our retreat?*
Which Training are you applying for?*
- September 24th-29th 2024: Advanced Sharing for KAP practitioners at The Menla Retreat Center in Phoenicia, New York
- February 23rd-28th 2025: KAP fundamentals at The Bishop's Ranch in the Dry Creek Valley of Sonoma
- April 25th-27th 2025: Dharma K at Menla
- May5th-11th 2025: Fundamentals at Menla
Application Fee*
Price:
Please note that the application fee is non-refundable
Deposit*
Price:
This $400 deposit will be applied to Tuition upon acceptance.
If you've been given an administration code please enter it here
Total
$0.00
Credit Card
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Home Phone Number
Cell Phone Number
May I leave a message?*
- Yes
- No
Date of Birth
MM slash DD slash YYYY
Gender
Education
Grade completed, any post-secondary
Current Occupation
Medical Intake
Person to alert in the event of medical emergency*
Please list name, address, relationship and phone number.
Family Doctor
Please list name and phone number.
Relationship Status
- Single
- Married
- Partnered
- Separated
- Divorced
- Widowed
Spouse/Partner
Please list name and phone number.
Children
Please list gender and age.
Allergies
Please list
Current Medications*
Please include dose and frequency
Journeying -- Altered States*
We realize this is a confidential and personal area-all information is only read by the primary training team; some have experience, some have none. It helps us know you better. Please list medicines, their frequencies and last date used
Have you had any experiences with Ketamine? How many times? Any problems or side effects?*
What influence have these journeys had on your life?
Hidden
Do you feel you are experienced with journeys?
- Yes
- No
Have you had any challenging or problematic experiences? Is there a difficulty in having ketamine experiences in the retreat due to past history, and cultural constraints?
Please describe and indicate the substance(s) involved.
Describe any insights and integrations you may have made in relation to your Journeys.
What are your concerns about doing journeys?
Please describe any concerns that might affect your ketamine experiences with KTC.
Medical Illnesses, Current and Past
Have you had previous psychological care or counseling?*
- Yes
- No
If yes, please list your treatments, their duration, method, and if you are currently in treatment.
Provide no more than a few words describing the rationale for treatment.
Have you been prescribed psychiatric medications in the past?
If yes, please name the medication(s) and the amount of time you took it (them) - as well as your memory serves.
Have you ever been hospitalized for a psychological difficulty?*
- Yes
- No
If yes, please provide more info.
Please give the dates and the nature of the difficulty at the time.
How would you rate your current sleeping habits?
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very Good
Please describe any difficulties you experience with your appetite or eating patterns.
Are you currently experiencing significant sadness, grief, or depression?
- Yes
- No
If yes, for how long?
Are you currently experiencing anxiety, or panic attacks?
- Yes
- No
If yes, for how long?
How often/amount do you drink alcohol?
Have you had a dependency on alcohol or recreational drugs?
- Yes
- No
If yes, please describe
Have you ever or do you now have a history of prescription drug dependency or abuse?
- Yes
- No
If yes, please explain what substance and nature of dependency or abuse
Females: Are you or could you be pregnant?
- Yes
- No
Hidden
If applicable, what form of BC do you use?
Hidden
If you are in menopause, do you use HRT or other hormones?
- Yes
- No
In your own words, is there a personal concern that you may wish to address in our sessions?
- Yes
- No
Feel free to describe this in as much or as little detail as you wish. What do you consider some of your strengths? Weaknesses?
Please list with dates any significant trauma you have experienced: violence—physical, sexual, emotional; abuse; natural occurrences; etc. Please comment on any lingering feelings or symptoms such as those that occur with PTSD. Please describe experiences of personal and social injustice that relate to your gender identification and being a BIPOC person?
Do you have a view of how you wish our retreat to deal with this? Are you concerned about sharing this in a confidential group setting?
Do you meditate?
- Yes
- No
If yes, how often do you meditate?
If yes, what meditation practices have you learned and use?
Do you consider yourself to have a spiritual/contemplative practice?
- Yes
- No
What is the nature of your social/personal support structure in your life? (i.e. Partners, Friends, Family that you can call and rely upon for help and support?
What is your sense of your coping mechanisms? What strategies do you utilize to deal with stress and life’s challenges?
Integration

This work may lead to profound shifts in your life and it is ideal to have a framework of resources in place ahead of time to support you before, during and after sessions. Having support to help you integrate the experience can help you to get the most benefit from the work.
What practices do you feel will be most beneficial in helping you to integrate this retreat experience into your life?
(i.e. speaking with trusted persons, art, bodywork, journaling, time in nature, etc.)
What resources do you have access to for supporting your integration and how will you put them to use? If you are not a prescriber, have you identified one with whom you can form a team to do KAP or ketamine work?
Please feel free to add any additional information you would like us to know and consider.
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What friend, loved one, counselor or other trusted person(s) do you speak with about this work? What are their dispositions towards you in pursuing this work? Are they supportive?
Hidden
What resources do you have access to for supporting your integration and how will you put them to use?
Team Building

We are presenting a team based protocol for doing Ketamine Assisted Psychotherapy in which a physician or psychiatrist who is able to assess a patient and prescribe ketamine works in concert with members of the psychotherapeutic professional community to provide a multi-modal therapy, guiding patients through their sessions and follow up integration work. Ideally, you and your team will all participate in this program. If this is not possible, KTC will make recommendations for potential team partners from within the training; though whether or not you choose to work together in the future is left to your individual discretion. We encourage and enable connections, knowing some do not know others who may be in their area.
Hidden
Have you identified your future team members for providing Ketamine Assisted Psychotherapy once you have completed this training?
- Yes
- No
Hidden
If you are a physician who can prescribe ketamine, do you have potential non-medical team members in mind?
- Yes
- No
Hidden
Can you encourage them to apply and to take this training at the same time?
- Yes
- No
Hidden
If you are a Psychotherapist, Clergy or Hospice worker, are you able to identify a physician, who you would like to be on the team, who will prescribe the medication and provide medical supervision on your team?
- Yes
- No
Hidden
Are you able to encourage them to apply and to take this training at the same time as you?
- Yes
- No
Please read and sign: I understand that accurate reporting of the above information is necessary to help ensure that I have a safe and beneficial experience. I realize that failure to provide accurate information may compromise my experience, and I have answered this questionnaire truthfully to the best of my ability. I am responsible for my health and I understand that my participation in this event may pose some risks. To the best of my knowledge, I am in good physical condition and I am not aware of any physical or psychological infirmity, which would place me at risk to participate in any way. In the event of a medical emergency, I agree to seek emergency medical care and give permission to initiate contact with emergency medical providers. I will utilize appropriate support so that I may optimize the benefit of this experience, and reduce any risks. In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the event’s leader, organizers, hosts and participants from any and all liability, claims, demands, or course of action whatsoever arising out of, or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted. I agree to indemnify and hold harmless those with whom I engage this work. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise. In signing this release, I acknowledge and represent that I have read, understood and signed the form voluntarily; I am an adult, of at least nineteen years of age or older, and fully competent; and I execute this Release for full, adequate and complete considerations fully intending to be bound by same. This waiver applies to all present and future work with the Ketamine Training Center and its Facilitators. *
Your typed name serves as your signature.*
First Last
Today's Date*
MM slash DD slash YYYY
Further Includes: Once we receive your application you will be prompted for the application fee of $500. Your application is not complete without payment. Please remember to email your credentials to ketaminetrainingcenter@gmail.com.
Please submit your personal narrative here
Have you worked with Ketamine previously? Please describe in a few paragraphs your background and interest in this training. Tell us anything pertinent regarding your personal development and progress through the stages of licensure, commissioning or ordination that might relate to your interest in this program. Include descriptions of your training in therapy or spiritual direction. Please describe any previous experience with non-ordinary states of consciousness that you believe are relevant to this training program Please share with us briefly what you hope to do with this training in your work in the world.
Important: Please only click the submit button below ONCE. Clicking the button more than once may result in multiple charges on your credit card.

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