application form Private retreat Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Birth Date *Gender *City, (State), Country of Residency *What plant medicine is calling you for this retreat? *AyahuascaPsilocybinWhat kind of retreat are you looking for? *Solo RetreatCouples RetreatFamily RetreatFriends RetreatWhen would you like to join us for a private retreat? Please specify the dates: *Why are you interested in embarking in a plant medicine retreat with us?" *Do you have any allergies? (Yes/No) If yes, please specify: *Do you have any dietary restrictions? (Yes/No) If yes, please specify: *Do you have any pre-existing physical or mental health conditions? lf yes, please provide details: *Are you currently taking any medications? If yes, please provide details: *Did you have accidents, operations, other health problems in the past? *Are you a smoker? *Have you had any past experiences with ayahuasca, psilocybin or other substances (tobacco, alcohol, cannabis, cocaine, psychedelics, amphetamines, MDMA, etc.)? If yes, please provide details: *Do you have a history of addiction (substance abuse, alcohol, etc.)? lf yes, please provide details: *Do you have any spiritual or personal development practices? (Yes/No) If yes, please specify: *How did you hear about us? *Is there anything else you would like us to know or consider regarding your application? *Checkbox *I hereby declare that the information provided in this form is accurate and complete to the best of my knowledge.I consent to the use of my personal information for the purpose of this retreat and understand that my information will be kept confidential. Why (Yes/No) us? Total$0.00Submit
