The Legal Stuff
Thank you for registering for the ketamine retreat! The Wellward Team looks forward to welcoming you to Pine Knoll Farm April 22-23, 2023.
Please take a moment to review of consent & wavier, This must be signed to continue
Informed Consent For Participants in Ketamine Sessions
The purpose of this document is to provide you with a clear understanding of the nature of Ketamine and of your role in the sessions.
These Ketamine sessions are organized and facilitated by Danesh Mazloomdoost/Gillian Vallis/Ketamine group facilitators. The work that is carried out in the session will focus on your personal growth and therapeutic self-work through the use of Ketamine.
Research from Johns Hopkins, Imperial College London, NYU, and other universities support long-established anecdotal evidence that use of Ketamine in controlled settings and with the proper preparation and integration can improve our emotional states and reconnect us with nature. For millennia, various psychedelics have also been used in a variety of settings for recreational, therapeutic, and religion-spiritual purposes and for personal growth.
Today, Ketamine is experiencing a resurgence of interest. The United States FDA has recently granted Ketamine status for treatment resistant depression, major depressive disorder, treatment resistant depression, PTSD, and more. Still, most countries have instituted some level of regulation or prohibition of psychedelics or their active ingredients.
Working with Ketamine is not a substitute for medical, psychiatric or psychotherapeutic treatment, but can complement a therapeutic process and facilitate personal development. If you are currently receiving treatment of any kind and are not sure about whether to participate in a session or retreat, please check with your doctor or therapist first.
The effects produced by Ketamine may include changes in your perception of reality and way of thinking, visions (of abstract motifs or clearly identifiable images and scenarios), heightened emotions, access to detailed memories previously thought to be lost or forgotten, paranormal phenomena, the emergence of fears or difficult emotions (some of which may be associated with blockages in the body and be causing pain and tension), introspection, and perinatal or transpersonal experiences (in which you may experience your own death and rebirth).
At the physical level, you may experience nausea, vomiting, chills, tingling, ringing in the ears, dizziness, tremors, shaking, sweating, and, in rare cases, fainting. Sometimes, especially if you have experienced Ketamine before, you may not notice any visionary effects. If that happens, it does not mean the Ketamine is not having an effect on other levels. The experience is more intense with eyes closed, and the best thing you can do in difficult times is to breathe slowly and deeply, go with the music, and have confidence in the process that the Ketamine is taking you through, and in the person(s) holding the session.
The Ketamine experience is not linear, but rather passes through different phases and cycles, some more pleasant (even euphoric), and others more unpleasant and difficult. You may temporarily experience the symptoms of mental illness, such as suspicion, paranoia and ‘delusions of reference’ (e.g. believing the whole world is watching you or that something is happening because of or for you). It is common to have several waves of these feelings during the experience. Most of us have at some time or another in our lives experienced these feelings, and although they may be uncomfortable, exposing ourselves to them in this way helps us to deal with and work through them. Remember, support is right there if you need it; just call out.
Although scientific studies show that in controlled environments Ketamine is relatively safe for people without serious physical or psychological problems, some people may experience adverse effects. These effects tend to be acute, such as a panic attack or psychotic episode with depersonalization, and there are some chronic cases, albeit very rare, in the form of anxiety, depersonalization, delirium or psychosis. The setting along with adequate preparation and integration are key to reducing the risks as much as possible.
If you agree to participate in this session or retreat, you will be required to answer a series of questions and to complete a medical form and questionnaire. You must agree to answer all questions honestly and to disclose any relevant personal information about your health. After the session, and periodically over the coming year, you may be contacted and invited to fill out the questionnaire again for the purpose of monitoring and measuring your psychological and physical progress.
Your facilitator is responsible for maintaining the confidentiality of any personal information. This includes your name, address, phone number and other information that could identify you.
If you have questions about the session or your integration process over the coming months, feel free to approach the facilitator(s). Your participation in the session is entirely voluntary and you are free to opt out at any time before the start of the session. However, you must endeavor at all times to follow the instructions of the team and facilitator(s) so your safety is not jeopardized. The facilitator(s)’s discretion may be used at any time to exclude you from participation in the session for any perceived impairment in your physical or psychological health that risks leading to problems for you during the session, or if for any other reason you do not meet the requirements for participation.
The person administering the Ketamine will know the strength of the substance and will adjust the dose for you on the basis of their age, gender, experience, sensitivity, health status and needs. The facilitators and their team are committed to protecting your physical and emotional security, integrity, and privacy throughout the process, and intend to provide you with psychological and physical support before, during, and after each session. We have an emergency protocol and commit to provide any necessary support should the need arise.
I, the undersigned, accept the conditions of participating in Ketamine sessions held by Danesh Mazloomdoost/Gillian Vallis/Ketamine group facilitators, and their team, and I declare that I am choosing to participate of my own free will, and Danesh Mazloomdoost/Gillian Vallis/Ketamine group facilitators has not provided any illegal substances.
I have not been coerced into participating in sessions by the organizers or by any other person; the decision to participate is mine alone, and is based on my own personal assessment of the effects, the exclusion criteria, the potential risks and benefits, the focus of the session and the commitment of the people facilitating it.
I am aware that I am to answer all questions honestly during the screening process and am required to complete questionnaires before and (sometimes) after the session. I agree to provide all the relevant information about my medical history, my mental and physical health and any other information that may serve to protect my health during this process.
I acknowledge that the information I provide to the organizers of this session is strictly confidential and will not be used without my approval for any other purpose than as described in the accompanying document. In addition, I agree to maintain confidentiality about this session, facilitator and all other participants attending.
The facilitator(s) have explained to me what to expect from the session and how it is intended to proceed. I am aware that I can ask questions about the session at any time and can change my mind about attending at any time before the session begins.
Once the session has started, I commit to not leaving the space without the consent of the facilitator(s), and I commit to following the instructions at all times, from the preparatory stage through to integration. I understand and agree that I can be excluded from participation in a session at the discretion of the facilitator(s). I understand that I will receive a copy of this consent form.
Waiver of Liability
Terms and Conditions and Waiver of Liability Claims
In consideration of participating in activities of a Ketamine Group Experience I agree to read all the information presented in these Terms and Conditions and Waiver of Liability Claims. I agree to comply with any and all rules and regulations communicated to me about these activities, including but not limited to:
- I KNOWINGLY AND VOLUNTARILY ASSUME ALL RESPONSIBILITY FOR RISKS AND LIABILITY FOR MY PROPERTY LOSS, PERSONAL INJURY, SERIOUS INJURY OR DEATH WHICH MAY OCCUR IN CONJUNCTION WITH MY PARTICIPATION IN Danesh Mazloomdoost/Gillian Vallis/Ketamine group facilitators ACTIVITIES; AND I HEREBY FOREVER RELEASE, DISCHARGE AND HOLD Danesh Mazloomdoost/Gillian Vallis/Ketamine group facilitators HARMLESS FROM ANY CLAIM ARISING FROM SUCH RISKS, EVEN IF ARISING FROM THE NEGLIGENCE OF Danesh Mazloomdoost/Gillian Vallis/Ketamine group facilitators, ITS MEMBERS, AGENTS, OR THIRD PARTIES.
I, on behalf of myself and any minors for whom I am responsible, our heirs, executors, administrators and assigns, hereby waive, release, discharge, and agree not to sue Danesh Mazloomdoost, Gillian Vallis, its officers, directors, members, employees, agents, volunteers, representatives, contractors and subcontractors, sponsors, affiliates, and if applicable, owners and lessors of equipment, installations and premises used for related activities, from any and all claims for damages, injuries, losses, liabilities and expenses which I may have or which may subsequently accrue to me, relating to, resulting from or arising out of my use of the facilitators’ property and/or participation in any of the facilitators’ programs, events, installations or activities, including any injury or damage to my mental or physical health, to my property, or to that of any other person or property.
- I acknowledge and understand that by participating in a Ketamine retreat experience, I may be exposed to environments that may present risks of serious injury, permanent disability, death, property damage, economic losses, emotional or psychological disturbance, and other risks, including but not limited to, those caused by:
(a) the actions, inactions or negligence of Danesh Mazloomdoost, Gillian Vallis, its agents, Members, or third parties; (b) rules and regulations regarding the activities; (c) conditions of the premises or equipment used; (d) all dangers to persons and property associated with vehicular traffic; (e) infection from pools, streams, kitchen facilities or other human impacted or natural conditions; (f) drowning in pools or natural bodies of water; (g) temperature and weather extremes including flooding, drought, high winds, earthquakes; (h) streams, caves, steep terrain, bluffs, falling rocks; (i) wildfires, falling trees; (j) wild animals including biting insects, venomous spiders and snakes, bears, mountain lions, and so forth.
I further acknowledge and understand that there may also be other risks both obvious and that are not obvious, known, or foreseeable at this time.
- I understand that some Ketamine group retreat activities may include psychoactive substances that may have undesired side effects, including but not limited to: (a) nausea and vomiting; (b) mental illness episodes; (c) impaired bodily movement; (d) inability to safely drive or operate other machinery.
- Should I find that any condition or activity (e.g. administration of a psychedelic substance at Pine Knoll Farms property or anywhere on the event site), is unsafe or offensive to me, I acknowledge that I can avoid such condition or activity by, among other things, leaving the vicinity. I agree not to leave the property, however, if I am under the influence of any psychoactive substance.
- Unless I am known to be in possession of a valid health care directive to the contrary, I consent to have first aid and medical treatment that may be deemed advisable in the event I am incapacitated due to injury, accident and/or illness while on property or engaged in the Ketamine Group Retreat activities. I release Danesh Mazloomdoost/Gillian Vallis/all entities related to each of them, and all persons participating in any first aid or medical treatment from all liability for any such actions unless they are grossly negligent.
- “Participant” is the person named on the intake form.
- Danesh Mazloomdoost/Gillian Vallis each reserves the right to accept or decline a participant at any time. The participant agrees to take part in group sessions with Danesh Mazloomdoost/Gillian Vallis, and their representatives.
- Danesh Mazloomdoost/Gillian Vallis will do its utmost best to ensure the safety and comfort of the participant within the remit of this session. The participant, in turn, agrees to exercise caution and consideration for him or herself and for others during this session, including at the location of the session, and in other environments, and indemnifies Danesh Mazloomdoos/Gillian Vallis and their representatives against claims for injury, loss, damage, misadventure or inconvenience at all stages.
- The participant has made confidential disclosures regarding medical conditions and/or use of medications. The participant declares that all such information is truthful and complete. Psychedelic facilitators also agree to keep these in confidence unless required by law to divulge them and/or for the resolution of any dispute. The participant agrees to inform Danesh Mazloomdoost/Gillian Vallis/their representatives of any change in circumstances.
- Danesh Mazloomdoost/Gillian Vallis/their representatives have recommended that the participant, prior to entry into this Agreement, seeks and obtains health or medical advice as to the effect of Ketamine, and in combination with any medication they are taking. The participant avows that they, having done so or deemed it unnecessary, is in a physical and mental condition appropriate to the activities described on the website and agrees to participate at their own risk. The responsibility for taking accurate and timely health precautions, professional medical advice, and for acting upon this (or otherwise) is solely with the participant.
- Danesh Mazloomdoost/Gillian Vallis/their representatives reserve the right to make changes to the time and date of the session, or cancel the session if necessary. Danesh Mazloomdoost/Gillian Vallis/their representatives are not responsible for costs that the participant may incur, or have incurred, such as transportation or the purchase of any goods or materials.
- Danesh Mazloomdoost/Gillian Vallis/their representatives will do its best to help with any special requests or needs that the participant may make or have but are not beholden to do so, and the participant understands that such requests may need to be paid for by the participant.
- The participant will not hold Danesh Mazloomdoost/Gillian Vallis/their representatives liable for damages, injuries, losses, accidents or delays, including willful or negligent acts, failures to act or breaches of contract by any parties which supply goods or services for this event.
- The participant is advised to take out suitable medical and travel insurance for their journey and this event, covering personal accident, medical expenses, losses, repatriation costs and all other expenses which might arise as a result of loss, damage, injury, delay or inconvenience. Danesh Mazloomdoost/Gillian Vallis/their representatives are not liable for such expenses.
- The participant agrees to show respect for the environment he or she is in, and to act with courtesy and dignity towards members of the retreat and Danesh Mazloomdoost/Gillian Vallis/their representatives. Should the participant commit any illegal act, or should their behavior adversely affect the facilitator(s) they may be asked to leave the Pine Knoll Farm grounds and shall have no entitlement to complaint.
- The participant has read, understood, and voluntarily signed this document and agrees that no representations, statements, or inducements have been made by Danesh Mazloomdoost/Gillian Vallis/their representatives for him/her to take part in this program or to sign this agreement. By signing the participant waives certain legal rights, including the right to sue.
I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THESE TERMS AND CONDITIONS AND WAIVER OF LIABILITY CLAIMS. I UNDERSTAND THAT ALONG WITH GAINING THE BENEFITS OF Danesh Mazloomdoost/Gillian Vallis/their representatives ACTIVITIES I ALSO GIVE UP SUBSTANTIAL RIGHTS, AND I DO SO KNOWINGLY AND VOLUNTARILY WITHOUT ANY COERCION OR DURESS.
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.