• 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.

  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 Dharma K?*
• 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
  AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
  Country
• Email*
  
• Home Phone Number
• Cell Phone Number
• May I leave a message?*
  • 
    Yes
  • 
    No
• Date of Birth
  
  MM slash DD slash YYYY
  
• Gender
• EducationGrade completed, any post-secondary
• Current Occupation
• Medical Intake

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• Person to alert in the event of medical emergency*Please list name, address, relationship and phone number.
• Family DoctorPlease list name and phone number.
• Relationship Status
  • 
    Single
  • 
    Married
  • 
    Partnered
  • 
    Separated
  • 
    Divorced
  • 
    Widowed
• Spouse/PartnerPlease list name and phone number.
• ChildrenPlease list gender and age.
• AllergiesPlease list
• Current Medications*Please include dose and frequency
• Have you had journeying or other altered states experiences?*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?
• HiddenDo 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
• 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

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  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.
• 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.

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• Please submit your personal narrative hereHave 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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