INVITATION FOR THERAPISTS & HELPING PROFESSIONALS

KAPPI Hour™

Ketamine
Assisted
Psycholytic
Preparation
& Integration

A guided burnout prevention experiential.

Registration for

December 11th @3pm CT | 4pm ET

Full Name *

Street Address *

Country *

State *

City *

Postal Code *

Phone *

Email *

Professional role *

e.g., licensed therapist, social worker, nurse, counselor, coach

1. Do you currently hold a valid ketamine prescription? *

Yes — I have an active prescription from a licensed prescriber

No — I do not have a prescription (psycholytic experiential requires a low dose)

2. Who is your prescriber? *

Journey Clinical

Joyous

common.other_option

Write your prescriber's name here if not listed above:

3. Route of Administration *

4. It is outside the facilitator's scope of practice to provide medical advice, therefore: *

I agree to follow my prescriber's instructions.

5. Prescribed dose you plan to take for KAPPI HOUR (mg): *

6. Have you had prior experience with ketamine? *

No (this would be my first time)

Yes

If yes, is there anything you would like me to know about your previous experience?

7. Will you have a chaperone available during the session? (If required by prescriber) *

Yes

Name and Phone Number of Chaperone and/or Emergency Contact

8. How did you hear about KAPPI HOUR™? *

9. Informed consent — please read and check each item *

I understand that KAPPI HOUR™ is a guided group experience, not a clinical treatment or psychotherapy session.

I confirm I hold a valid ketamine prescription and will follow my own prescriber's instructions regarding dosage. No medication is provided by In Tune.

I understand that ketamine use during the session is my own responsibility and that I will not drive or operate machinery according to prescriber's recommendations.

I agree to keep confidential what is shared by other participants during the group.

I understand I may pace my own experience and that I can choose not to take medication on any given session.

I understand that the facilitator will contact my chaperone or emergency contact if a safety concern arises during the session. I understand if there is a perceived risk of harm to myself or others, the facilitator will call 911.

If checking vitals is required by prescriber, I’ll provide info. and I will not proceed with medicine if vitals are above max thresholds according to prescriber's recommendations.

I understand that my registration fee reserves my spot, since spots are limited, no refunds will be granted.

Signature *