Date of birth
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Phone (include country code)
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Email
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Address line 1
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Address line 2 (optional)
City
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Postcode
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Country
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Profession
Which retreat are you applying for?
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21-23rd February 2025 13-15th June 2025
How did you hear about the retreat?
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Why are you interested in this experience? What is your goal? How might it benefit you?
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Have you had any difficult or problematic experiences during altered states of consciousness? Please describe, including any substance taken and what was difficult about those experiences.
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For anything above, please state whether it’s a past or current issue, its severity, and any treatment.
For anything indicated above, please indicate the doses you’re taking.
Do you take any other supplements regularly? Please describe.
Have you had adverse reactions to medications or supplements? Please describe.
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Are you allergic or intolerant to anything?
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Briefly describe any surgeries you’ve had and when.
Briefly describe any other hospitalisations you’ve had and when.
If yes, please describe who the person is, the diagnosis, when it started, and its impact.
Do you have any suicidal thoughts, or have you ever made a suicide attempt? Please describe in detail.
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Are you currently under the care of a healthcare or mental health professional? Please describe.
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Is there anything else about your physical or mental health that would be relevant to disclose?
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How often do you use alcohol, tobacco or cannabis, and in what contexts?
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For anything indicated above, please describe the substance, how regularly you used it and at what point in your life, dose and purpose (recreational, therapeutic, ceremonial).
Is there anyone you can rely on for support after the experience?
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Preferred room choice (please note that these are booked on a first come, first served basis only):
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4-bed room 2-bed room 2-bed room (minor mobility difficulties)
If it is someone else, please provide their name.
If you are human, leave this field blank.
