Ketamine Screening Questionnaire

Thanks for your interest in this one-day retreat.

The event will be held at my office in North Hyde Park.

Upon arrival the day of the retreat, we will check your temperature, oxygen saturation, and blood pressure. You will be given an oral dose of Zofran to eliminate nausea, a potential, but somewhat rare, side effect of ketamine.

Following the quick medical check, the group will gather and settle in, share intentions, and have a brief group discussion.

The experience itself is introspective. You will relax on a padded floor mat with pillows and blankets. During the experience, you’ll have the option to wear eye shades. Music will play over speakers in the room. The experience usually lasts one to two hours. Afterward, group members will share and discuss their experiences, relating them to “real life” and their intentions, when possible.

There will be snacks and beverages available after the experience. (Feel free to bring your own.) You will need to arrange a ride home. Driving is prohibited until the following morning.

The fee for this event is paid by Venmo to Leah Benson. This includes the $250 non-refundable medical consultation fee.

The next steps are as follows:

1. Fill out and submit the ketamine screening questionnaire to see if you qualify for this experience.

2. 15-20 minute psychological screening by phone with Leah.

If you qualify:

3. Pay for the retreat and schedule and your medical consultation with our prescriber. Allow for up to 1 hour for this call.

PLEASE NOTE: The medical consultation fee is non-refundable whether or not you are cleared for ketamine. All efforts will be made to qualify you for the ketamine experience before you reach the stage of medical consultation. However, there is no guarantee you will be cleared by the prescriber. It is imperative that you are as honest as possible regarding your medical status and history in the initial screenings to avoid the possibility of not being cleared.

Medical consultations are scheduled directly by you with the prescriber after payment is made via Venmo to Leah Benson. Scheduling and schedule changes are at the discretion of the prescriber. You may be required to remit a second medical consultation fee ($250) if you cancel or attempt to reschedule a consultation. The medical consultation must be completed by the deadline indicated on the calendar.

Failure to meet deadlines may result in forfeiture of your registration fees.
However, if you do not pass the medical consultation, registration fees less the medical consultation fee of $250 will be refunded.

The group is limited to 8 adults, on a first-come, first-served basis.
All registration deadlines are listed on the calendar. No refunds will be issued after that date.

Before you are able to receive Ketamine treatment, we need to make sure that it is safe for you to do so. To that end, we need information about the possible factors that could enhance your risk to experience unintentional adverse effects. Please fill out the questionnaire carefully and honestly. This form will subsequently be assessed by the prescriber.

"*" indicates required fields

Name
Address
MM slash DD slash YYYY

Do you have a history of problems with anesthesia?*
Have you experienced chest pain?*
Do you have a heart condition?*
Do you have a history of hypertension or low blood pressure?*
Have you ever had a stroke?*
Have you ever undergone surgery to your head?*
Have you ever had a severe head trauma?*
Have you ever lost consciousness without any known reason?*
Do you have asthma, bronchitis, or any other breathing problem?*
Have you had hepatitis, liver disease, or jaundice?*
Do you have or have you ever had kidney disease?*
Have you ever (at present or in the past) suffered from a brain-related, neurological illness?*
Do you suffer from frequent severe headaches?*
Do you have another chronic illness/disorder not yet listed above?*
Are you currently taking antibiotics?*
Are you taking your medications as prescribed?*
(Women) Are you pregnant, or is there a chance that you might be?*
(Men) Do you take Viagra, Cialis, or other erectile dysfunction medicines?*
Do you or someone in your family have a psychiatric illness/disorder?*
Do you or someone in your family have schizophrenia or a psychotic illness?*
Do you have sleeping problems such as Obstructive Sleep Apnea?*
Do you experience panic/anxiety attacks?*
Have you ever suffered from substance dependence or abuse?*
Do you experience dissociation, which is a sudden feeling of beingdetached or disconnected from reality and your immediate surroundings, often occurring during a time of stress?*
Treatment History
Current Medications
Medication
Dosage
Time Period
 
I answered all questions to the best of my knowledge and belief:
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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Leah Benson, LMHC and Certified Bioenergetic Therapist
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  • 1719 W Carmen St, Tampa, FL 33606
  • (813) 452-0111
  • Leah @ LeahBensonTherapy . com
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