Applications | The Ketamine Training Center

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.

Applications are reviewed and applicants will be notified of acceptance. Acceptance is not automatic.

Name*

First Last

How did you hear about this training?*

Which Training are you applying for?*

Advanced Sharing at Menla in The Catskills, NY 9/19 - 9/24
Fundamentals Training at Menla in The Catskills, NY 10/24 - 10/29

Application Fee*

Price:

Please note that the application fee is non-refundable

Deposit*

Price:

This $400 deposit will be applied to Tuition upon acceptance.

How would you like to pay the application and deposit?*

Credit Card
Paypal

If you've been given an administration code please enter it here

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone Number

Cell Phone Number

May I leave a message?*

Yes
No

Date of Birth

Gender

Education

Grade completed, any post-secondary

Current Occupation

Medical Intake

Person to alert in the event of medical emergency*

Please list name, address, relationship and phone number.

Family Doctor

Please list name and phone number.

Relationship Status

Spouse/Partner

Please list name and phone number.

Children

Please list gender and age.

Allergies

Please list

Current Medications*

Please include dose and frequency

Journeying -- Altered States

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

Do you feel you are experienced with journeys?

Yes
No

What influence have these journeys had on your life?

Have you had any challenging or problematic experiences?

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?

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

If applicable, what form of BC do you use?

If you are in menopause, do you use HRT or other hormones?

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.

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 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

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 friend, loved one, counselor or other trusted person(s) do you speak with about this work? What are their dispositions towards you in pursuing this work? Are they supportive?

What practices do you feel will be most beneficial in helping you to integrate this 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?

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.

Please note that the Dharma K event is open to the community at large regardless of your ability or intention of being able to work with others using Ketamine as a psychotherapy. If you are applying for Dharma K in that capacity some of the questions below will not be applicable to you. Feel free to mark those questions with n/a when applicable.

Have you identified your future team members for providing Ketamine Assisted Psychotherapy once you have completed this training?

Yes
No
n/a

If you are a physician who can prescribe ketamine, do you have potential non-medical team members in mind?

Yes
No
n/a

Can you encourage them to apply and to take this training at the same time?

Yes
No
n/a

If you are a Psychotherapist, Clergy or Hospice worker, are you able to identify a physician, who you would like to be on the team, who will prescribe the medication and provide medical supervision on your team?

Yes
No
n/a

Are you able to encourage them to apply and to take this training at the same time as you?

Yes
No
n/a

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*

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.

Please submit your personal narrative here

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.