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About About Us Therapists Podcast Blog Media & Recognitions 'Wellness Wednesday' Online Broadcast Series with Dr. Lauren Become a Client Services Psychotherapy Teletherapy Hypnosis / Hypnotherapy ADHD Skills Coaching Reiki Energy Healing LPC Supervision $60 for 60 Minute - Wellness Consultations Speaking Engagements Corporate Offerings Workshops Ketamine-Assisted Psychotherapy Services Individual Ketamine-Assisted Psychotherapy (KAP) Ketamine-Assisted Psychotherapy Group Retreats Shop Events Wellness Junction Resources Resources Lists Medication Management Resources Crisis Hotlines Substance Abuse Support Groups Must Read Books Recommended Podcasts Mental Health Resources Race Based Trauma Contact

Ketamine Retreat Inquiry

Are You Interested in Attending One of Our Upcoming Retreats?

Take the Next Step and Fill Out The Form Below

Name *

First Name

Last Name

Email *

Phone *

(###)

###

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I'M INTERESTED IN THE FOLLOWING RETREAT DATE(S): *

NOTE: This does not secure your spot.

Transformative Healing Retreat - Friday, October 27th, 9am-2pm

Veterans Group - Friday, November 10th 9am-2pm

Future Dates

DO YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS:

(Past or Current)

Metabolic/Endocrine Issues *

Hyper/Hypothyroidism

Yes

If yes, please specify

Kidney or Liver Disease *

Yes

If yes, please specify

Cardiovascular Issues *

High Blood Pressure, Heart Attack, Heart Disease, Hypertension

Yes

If yes, please specify

Respiratory Issues *

Asthma, Sleep Apnea, Pulmonary Hypertension

Yes

If yes, please specify

Substance Abuse Disorder *

Alcohol, Marijuana, Cocaine, Ketamine, Methamphetamines, Heroine

Yes

If yes, please specify

Seizure Disorder *

Yes

If yes, please specify

Stroke *

Yes

If yes, please specify

Traumatic Brain Injury *

Yes

If yes, please specify

Any Chronic Illnesses Not Listed: *

Please describe below

DO YOU OR A FAMILY MEMBER SUFFER FROM:

(Please check all that apply)

Depression: *

Self

Family

Significant Other

None

PTSD *

Self

Family

Significant Other

None

Schizophrenia *

Self

Family

Significant Other

None

Suicidality *

Self

Family

Significant Other

None

Anxiety and/or Panic Attacks *

Self

Family

Significant Other

None

OCD *

Self

Family

Significant Other

None

Have you had any history of problems with anesthesia? *

Yes

Are you pregnant or could you be? Nursing? *

Yes

Are you on medications? If yes, please list them below. *

Are you currently or have you been in therapy in the past? *

Please specify length of treatment and approx. last session date

Discuss the reasons you are seeking KAP *

How did you hear about our KAP Retreats? *

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM.

Thank you for your submission! You will hear from us within 24-48 business hours.

Best,

Del Ray Psych & Wellness

1900 Mount Vernon Avenue,

Alexandria, VA, 22301,

United States

5712810338 office@delraypsych.com

Hours

1900 mt. vernon ave alexandria va, 22301 · 571-281-0338 · OFFICE@delraypsych.com

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