questionnaire

Take a moment to read and respond — your safety matters.

To ensure your safety and well-being during the retreat, please complete this quick questionnaire. It helps us confirm there are no contraindications for ketamine treatment.

Once reviewed, we’ll send you a checkout link to finalize your registration.

Name

What are your goals for the Minds & Mountains Retreat?

Do you have experience with Ketamine or other psychedelics? (If yes, please explain)

Have you ever had an adverse reaction to ketamine or other psychedelics ("a bad trip")? (If yes, please explain)

What medical or psychiatric conditions have you ever been diagnosed with?

What medicines are you currently taking?

What medicines are you allergic to? (Please describe reaction to each)

What substances including marij*ana are you currently using and how often?

Do you have a history of substance use disorder (If yes, please explain)

Are you currently under the care of a psychiatrist or psychologist?

Do you have a history of any of the following? Please check any you have been diagnosed with;

Note;

Females: Are you pregnant or breastfeeding ? (If male just put n/a please)

Take a moment to read and respond — your safety matters.

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