Retreat Registration Form (Netherlands)

In order to register for the retreat, please fill in the form below. All information provided is kept confidentially and we rely on your honesty and accuracy to help us better evaluate whether our psychedelic retreats are a good option for you.

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If you are dyslexic and it feels too much to fill in this form, please contact us to see what would be the best way to send us your reply.

Retreat Registration form

Name & Surname

First

Last

Date of birth

Gender you identify with

Phone (include country code)

Address line 1

Address line 2 (optional)

City

Postcode

Country

Profession, Work or Study

Which retreat are you applying for?

Why are you interested in this experience? What is your goal? How might it benefit you?

For anything above, please state whether it’s a past or current issue, its severity, and any treatment.

Are you experiencing any of these symptoms on a regular basis?

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.

Are you allergic or intolerant to anything?

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.

Are you currently pregnant or breastfeeding? Are you planning to have a child soon?

Planning to have a child soon

Pregnant

Breastfeeding

NONE OF THE ABOVE

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.

Are you currently under the care of a healthcare or mental health professional? Please describe.

Is there anything else about your physical or mental health that would be relevant to disclose?

How often do you use alcohol, tobacco or cannabis, and in what contexts?

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.

Which payment group does your contribution fall into (including all taxes)?

According to the payment group you choose, please enter the amount you will be contributing.

Preferred room choice (please note that these are booked on a first come, first served basis only):

Please indicate any special dietary requirements.

Does responsibility for participation in this retreat lie with yourself or a third party (e.g. a corporation)?

Myself

Someone else

If it is someone else, please provide their legal name.

By submitting this form you consent that your information is processed according to data protection regulation.

I consent

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Contact Us

Email: contact@consciousgrowth.eu

Book a call with us

Legal Note

Taking psychedelic truffles in our retreats is subject to a registration process. Please consult the FAQs for a list of contraindications. Conscious Growth does not offer therapy or treatment for physical or mental health conditions during the retreats.

In accordance with Dutch law, we use exclusively psilocybin truffles that are legal across the country. You can read more about the legal aspect here.

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