Date of birth
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Gender you identify with
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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, Work or Study
Which retreat are you applying for?
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21-23rd February 2025 13-15th June 2025
Why are you interested in this experience? What is your goal? How might it benefit you?
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For anything above, please state whether it’s a past or current issue, its severity, and any treatment.
Please list all the prescription medications you’re taking, including name, dose, how long you have been taking it and any side effects you’ve experienced.
Please list all the supplements that you take on a regular basis.
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 serious accidents you’ve been involved in 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 any substances that you’ve taken, please provide its name, how regularly you used it and at what point in your life, dose and purpose (recreational, therapeutic, ceremonial).
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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Which payment group does your contribution fall into (including 21% VAT)?
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Regular (€1100-1500) Accessible (€885-1100) Supporter (€1100-1900)
According to the payment group you choose, please enter the amount you will be contributing.
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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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2-bed room 2-bed room (minor mobility difficulties) 4-bed room
Please indicate any special dietary requirements.
If it is someone else, please provide their legal name.
If you are human, leave this field blank.
