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2025 ATX Queer & Trans Ketamine Group Sit Application

Name: Selva Wellness Collective
Address: 1621 West 6th Street, Austin, TX, 78703
Telephone: (512) 222-6960

Thank you for your interest in joining our upcoming Ketamine-Assisted Psychotherapy (KAP) Group Sit. This immersive experience is designed for deep transformation, shadow work, and nervous system restoration, held in a safe, sacred container facilitated by trauma-informed clinicians and healing practitioners.

To ensure your safety and readiness for this experience, we ask that you complete the following application and medical screening form. This information helps us curate a supportive group and uphold the highest standard of physical and emotional safety for all participants.

Please know that all responses are strictly confidential and will only be reviewed by our clinical and medical team. Completion of this form does not guarantee participation. One of our team members will contact you to discuss next steps if it feels like a good fit at this time. If selected, you will be invited to place a deposit and complete a one-on-one medical screening with our psychiatric nurse practitioner (NP) prior to final acceptance.

CONTACT INFORMATION

Full Name *

Pronouns

Date of Birth

yyyy

Preferred Contact Method

Email Phone Text

Email *

Phone

Emergency Contact Name & Phone Number

Interested in Payment Plan, Sliding Scale, or Scholarship? *

Yes No

PERSONAL & PSYCHOLOGICAL HISTORY

What is your intention for joining this retreat? What are you hoping to explore or heal? *

Have you ever participated in a psychedelic session or plant medicine ceremony before? *

Yes No

Have you received a formal mental health diagnosis in the past? *

Yes No

Are you currently in therapy or working with a mental health provider? *

Yes No

Do you have any history of the following? *

Bipolar Disorder

Borderline Personality Disorder

Dissociative Identity Disorder

Active suicidal ideation or recent acute attempt (within the last year)

Active Eating Disorder

Recent trauma or dissociation in daily life (ongoing symptoms or triggers)

Hospitalization or psychiatric ideals

None apply to me

If you checked any of the above, please explain briefly

Do you currently take or have you recently used any substances (alcohol, cannabis, recreational drugs)? *

Yes No

Do you have any current concerns about your mental or emotional stability that we, before we should be aware of? *

Yes No

Have you ever, in group process work and deep-clearing during the retreat (offered 2 guided, trauma-informed settings)? *

Yes No Unsure - would like to speak with someone about this

MEDICAL SCREENING

Current Height and Weight *

(For dosage and safety purposes only)

Do you have any of the following medical conditions? *

Heart disease or irregular heart rhythm

Uncontrolled high blood pressure

Liver disease

Kidney disease

Pregnancy or nursing

Epilepsy or seizure history

Allergies to anesthetics or ketamine

Other serious medical conditions

No serious medical conditions

If you checked any of the above, please provide more detail:

Are you currently taking any medications? *

Yes No

Have you ever had an adverse reaction to anesthesia or ketamine? *

Yes No

Do you have any dietary restrictions, food allergies, or medical dietary needs? *

Yes No

Do you have any physical limitations or mobility concerns we should be aware of (e.g., hiking, yoga, swimming)? *

Yes No

How would you describe your current sleep quality and stress levels? *

Do you currently have a support system (friends, therapist, family, partner) in place to help you integrate after the retreat? *

Yes No

Please describe your support system briefly: *

Are you able to abstain from alcohol, cannabis, or recreational drugs for 72 hours before and after the retreat as part of your integration process? *

Yes No Unsure — I'd like to talk about this

Are there any current life stressors or destabilizing events happening in your life (e.g., divorce, grief, financial crisis) that may impact your experience? *

Yes No

CONSENT & NEXT STEPS

By submitting this application, I affirm that all the information provided is true and complete to the best of my knowledge. I understand that submitting this form does not guarantee participation in the retreat and that this information will be reviewed confidentially by the Selva Wellness Collective team.

If selected, I understand that: I will be contacted by a Selva team member for a brief follow-up conversation. I will be required to place a non-refundable deposit to reserve my spot. I will then schedule a mandatory medical screening with the psychiatric nurse practitioner (NP) to assess my eligibility for ketamine administration.