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.