KAPparel

Application

Online Application

Application Process

  • 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.
  • Please note that the application fee is non-refundable
  • This $400 deposit will be applied to Tuition upon acceptance.
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  • Grade completed, any post-secondary
  • Medical Intake

  • Please list name, address, relationship and phone number.
  • Please list name and phone number.
  • Please list name and phone number.
  • Please list gender and age.
  • Please list
  • Please include dose and frequency
  • 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
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  • Please describe and indicate the substance(s) involved.
  • Please describe any concerns that might affect your ketamine experiences with KTC.
  • Provide no more than a few words describing the rationale for treatment.
  • If yes, please name the medication(s) and the amount of time you took it (them) - as well as your memory serves.
  • Please give the dates and the nature of the difficulty at the time.
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  • 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.
  • (i.e. speaking with trusted persons, art, bodywork, journaling, time in nature, etc.)
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  • 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.
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  • 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. *
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  • 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.
  • 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.