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Healthcare Provider Form

Healthcare provider taking a (legal and above board) one year certification course in Psychedelic Integration for healthcare providers only.

Section 1: Provider Information

Personal Details

First Name

Last name

Credentials/Licenses

Areas of Expertise (select all that apply)

Ketamine-Assisted Therapy

Psilocybin Integration

Practice Information

Practice Model

Section 2: Integration Services Offered

Integration Services

Services Provided (check all that apply)

Individual Integration Sessions

Group Integration Circles

Integration Workshops/Classes

Therapeutic Approaches Used in Integration

Internal Family Systems (IFS)

Somatic Experiencing

Mindfulness-Based Approaches

Integration Services

Average Session Length

Typical Integration Program Structure

Section 3: Legal Psychedelic Experience Locations/Retreats

Legal Psychedelic Experiences

For Practitioners Who Organize/Recommend Legal Retreats

Do you organize legal psychedelic retreats or journeys?

Do you refer clients to specific legal retreat centers?

If Yes to Either, Please Provide Details

Retreats Organized

Location(s) (Country, Region)

Legal Status/Framework

Medicines Offered

Recommended Retreat Centers

Name of Center

Location

Section 4: Medical Support Network

Medical Support Network

For Medical Professionals

Medical Specialty

Prescribing Authority

Experience with Ketamine Therapy

For Medical Professionals

Do you collaborate with specific medical professionals for client referrals?

If yes, please list collaborating medical professionals (with their permission)

Nature of collaboration with medical professionals

Section 5: Training and Education Resources

Training & Education

Resources You Provid

Educational Materials

Workshops for Professionals

Resources You Recommend

Books

Articles/Papers

Section 6: Community Vetting and References

Community Vetting

Professional References

Please provide 2-3 professional references from the psychedelic therapy community

Professional References Name 1

Professional References Relationship 1

Professional References Name 2

Professional References Relationship 2

Professional References Name 3

Professional References Relationship 3

Community Contributions

How do you contribute to the psychedelic integration community?

Are you a member of any professional psychedelic organizations?

Have you published any research or educational materials on psychedelic integration?

Ethical Commitments

Do you adhere to a specific code of ethics for psychedelic work? If so, which one(s)?

How do you ensure client safety and informed consent?

Section 7: Logistics for Creating Retreats

Retreat Creation Logistics

For Those Interested in Creating Retreats

Legal Considerations

Have you researched the legal framework for psychedelic retreats in your target location?

Safety & Medical Protocols

Medical screening procedures

Emergency medical protocols

Retreat Staffing

Required staff positions

Staff-to-participant ratio

Venue Requirements

Physical space needs

Accommodation requirements

Integration Infrastructure

Pre-retreat preparation process

During-retreat integration activities

Financial Considerations

stimated budget ranges

Section 8: Additional Information

Additional Information

Is there any other information you'd like to share about your approach to psychedelic integration?

Are there specific populations or conditions you specialize in working with?

Ethical and Legal Considerations

Thanks for submitting!

30 Old Kings Highway S
Darien, CT 06820

191 Post Road W
Westport, CT 06880

Robert Romano

LCSW, LLC

Psychotherapist

Tel: 203.654.9094

LCSW@robromano.com

Robert Romano, Therapist Connecticut

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