Healing Our Heroes Retreat Initial Intake Form Name * First Name Last Name Email * City and State Enter your city and state of residence Phone (###) ### #### Which retreat are you interested in attending? Montana Florida Utah Colorado Are you a...? Veteran First Responder Retired Personnel from Intelligence Community Frontline Medical Professional Can you provide proof of service (DD214, etc...)? Yes No Do you need financial assistance to attend a retreat? Yes No Briefly describe your motivation(s) for attending one of our retreats and what you hope to gain from the experience General Medical History There will be a more robust medical intake screening prior to attending Do you have a mental health diagnosis? Yes No Unsure Are you currently under the care of a licensed mental health professional? * Yes (please explain below) No If you answered yes to the above question, please explain further. Do you have prior experience with Ketamine Therapy? Yes No If you answered yes to the above question, please explain further. Are you willing to follow up with a licensed mental health professional of your choosing following the retreat? * Yes No (please explain further below) If you answered no to the above question, please explain further. Any history of substance abuse? Yes (if willing, please explain further) No If willing and you answered yes to the above question, please explain further. Are you willing to share your current medications and health diagnosis before attending? Yes No Maybe If you were in crisis, who would you reach out to? Who is your emergency contact (name/phone number)? Is there anything else you would like us to know? Thank you!
