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Eagle's Eye Workshop
Reservation and Registration Form

"Liberating and Enlightening Minds"

You may either fill out this form online or download and print the form and then complete it manually. (You may use your browser's "print" function to print out a hardcopy of this form after you have filled in all the entries. Be sure to print the completed form before you hit the submit button on the bottom of the form.)

Eagle's Eye Workshop

Reservation and Registration

(Version 2b dated 4/13/2026)

Enter your email address

We will only contact you by phone if we are unable to contact you via email

Workshop / seminar choice
Private in-person session with Dr Roberts ($600)
July 2026 weekend workshop ($495)
September 2026 weekend workshop ($495)
November 2026 weekend workshop ($495)
Other preapproved workshop location and/or dates

(Exact dates for each future public workshop will be specified once the registrations for the minimum number of attendees and the retreat center availability have been confirmed). If your group has been preapproved for a private workshop, please specify the date and location below

For all other public or private group approved workshops, please specify the start date:
Month
Day
Year
deposit choice
Deposit for the workshop specified above ($100)
Payment will be made in full (the entire workshop fee)

If the workshop you selected is full, you will be placed on a waiting list pending cancellations

Enter the full name of the person if you have a specific roommate in mind for the retreat center.

If you will be staying offsite, please provide the name of the hotel. (Note that participants staying off-site will not be able to drive during the workshop - transportation to/from the workshop will be provided in this case)

Current Medications, Supplements and Allergies

Any meds known to have interactions with ketamine (e.g., antidepressants, antipsychotics, MAOIs, anti seizure meds): Yes / No If Yes, list:

Substance use and Safety Screening

Include Opioids, stimulants, benzodiazepines, or other substances

Last Use Date
Month
Day
Year

approximate date of last use

Psychiatric History

Have you ever been diagnosed with a mental health condition? (check all that apply):

Multi choice

Family history of psychosis, bipolar disorder, or other major psychiatric conditions? Yes / No If Yes please describe

Prior psychedelic and ketamine experiences (past)

Any adverse experiences (panic, dissociation, distress, physical reactions)? Yes / No If Yes, brief details:

Are you currently using ketamine or planning unsupervised use outside a supervised setting? Yes / No If Yes, frequency and substances:

Spiritual/Transformative experiences (past)

Have you had significant transformative or spiritual experiences with ketamine or other psychedelics? Yes / No If Yes, describe: setting, context, insights, and integration outcomes:

How have these experiences impacted your beliefs, values, or sense of meaning?

Have you faced challenges with integration or distress after experiences? Yes / No If Yes, describe:

What supports helped with integration (therapy, community, journaling, meditation, etc.)?

Planned ketamine journey and goals

Safety planning and emergency readiness

Do you have a trusted sober person available during and after the journey? Yes / No If Yes, name and contact information:

Do you have a medical emergency plan (clinic, hospital, emergency services)? Yes / No If Yes, details:

Are you currently under care for mental health or medical conditions? Yes / No If Yes, provider and contact:

Consent and Privacy

By signing in the "signature" box and typing my name in the box labeled "Printed name", I electronically sign this document and affirm it has the same effect as my handwritten signature under applicable law.

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Date signed
Month
Day
Year

(You may use your browser's "print" function to print out a hardcopy of this form after you have filled in all the entries. Be sure to print the completed form before you hit the submit button below.)

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