1 Personal Information

Full name *

Email *

Year of birth *

Country of birth

Current residence

2 Goals & Intentions

What do you hope to achieve from this retreat? *

List your 3 primary goals or concerns in order of priority

3 Lifestyle

How would you describe your life right now?

How do you currently manage stress?

Current stress level (1-10)

Current fulfillment level (1-10)

4 Health & Wellness

Current energy level (1-10)

Current health level (1-10)

What are your wellness goals?

Are you on any regular medication and have you recently taken SSRIs, psychiatric medications, or anti-depressants? Please specify

Do you have any psychiatric diagnoses?

How often do you experience anxiety?

What lifestyle adjustments are you willing to make?

5 Psychedelic Experience

Please describe your experience with psychedelics

7 Restrictions & Considerations

Do you have any dietary restrictions or preferences?

Do you have any allergies we should be aware of?

Do you have any phobias or strong fears?

Is there anything else you'd like us to know?

8 Emergency Contact Information

Emergency Contact Name *

Emergency Contact Phone Number *

9 Media Consent

Your story and experience can be a powerful inspiration for others seeking healing and growth. By sharing, you help us reach more people who could benefit from this work. We would be incredibly grateful for your consent.

Please check all that apply. This is completely optional.

Use my anonymized written review/testimonial: I consent to having my written feedback used on your website or promotional materials. My name and any identifying details will be removed. Use my photos/videos: I consent to the tasteful use of my photographs or videos for promotion. I understand that my name will not be used, no sensitive moments will be exposed, and there will be no close-ups or portraits.

10 Legal Agreements

Acknowledgement Agreement *
I have read and agree to the Acknowledgement Agreement

Liability Waiver *
I have read and agree to the Liability Waiver

11 Digital Signature

Please sign below

Sign with your mouse or finger

Type your full name to acknowledge your signature

Privacy & Confidentiality

This information is absolutely private and never shared with anyone. It is only seen by our chief facilitator and is not discussed with anyone else. See our Privacy Policy for more details.

Retreat Questionnaire