Request edit access
Autumn 2024 Women's Plant Medicine Retreat Application
October 24-27, 2024 in Alma, CO
Contact: northandsouthjourneys@gmail.com for any questions.

Please complete this form to take the first step towards attending the Women's Autumn Plant Medicine Retreat with Celeste and Laurel! We will use your responses to ensure this retreat is a good fit and also to personalize your retreat experience. Please answer these questions as accurately and honestly as possible. 

All information is kept strictly confidential. And if you’d prefer to chat with us first about it before applying please just email and we can set up a time. Please allow up at least two days to review responses. You’ll receive info on how to make payment (via Zelle) soon after you are accepted. Prices are at the bottom of this form.

Please note this retreat includes a group prep call, the inclusive retreat and 4 group integration calls after the retreat. During the retreat you will experience delicious food, a beautiful home with a view of huge mountains, plant medicine ceremony, shamanic group healing, sound healing, ritual and ceremony infused throughout, yoga, meditation, holotropic breathwork, connection and most of all lots of love and care. 

Here is the legal jargon that we are required to include. Please note that this retreat allows personal use of psilocybin mushrooms legal under the Natural Medicine Health Act of Colorado. Everything is completely voluntary. The facilitators (although highly trained and experienced) are not Licensed Facilitators through the State of Colorado. 

Thank you so much! 
Love Celeste & Laurel
Sign in to Google to save your progress. Learn more
Full Name *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
How did you hear about this retreat? *
Why are you drawn towards participating in this retreat? *
Do you have any goals, intentions, expectations for this retreat? *
What are you concerned about, if anything, regarding your retreat experience?
What experiences with psychedelics do you have (if any)? *
Do you have a relationship with Mushroom medicine? If so, please explain *
Sometimes, people may hope that one medicine journey will be all the transformation that they will need. Occasionally, this could happen. However, often this is a path that can span long periods of time. Please share your stage on this medicine path.  *
How comfortable are you with altered states of consciousness? *
very uncomfortable
extremely comfortable
What is your general level of sensitivity to psychoactive substances?

This can include substances like alcohol, caffeine, nicotine, prescription medications, supplements, over the counter medications, cannabis, and psychedelics.

Clear selection
Do you have any current or recent (within the last 6 months) mental health diagnosis or symptoms (also we realize many people are never diagnosed, if you have a feeling, or even self-diagnosis, please include that) *
Required
If you said yes to the question above, can you please explain a little more here. Include what treatment you have received and how severe it is. 
Do you have any past traumas that you believe could be relevant?  *
Have you experienced significant grief or loss that you are still processing?

This could be related the passing of a family member, friend, other person or pet who was close to you, or other significant life event.

 *
Do you have a first-degree relative with schizophrenia, bipolar disorder, or any other psychotic disorder?This question is required.*

A first-degree relative is a parent or sibling.

 *
Have you ever had thoughts of suicide or harming yourself? *
If you answered yes to above, can you please explain a little more. Include your last episode of ideation, if you had any attempts and when.  *
What kinds of healing have you received throughout your life? *
Required
Tell us about your experience with spiritual practices including meditation, yoga, breathwork, and any other contemplative or integrative practice.
 *
How would you describe your support network of family and friends?
 *
Do you currently have a therapist? *
Are you currently taking any SSRI's? If yes, please include type and dose. *
Please tell us about any physical conditions that may limit your mobility or compromise your health:

Please be sure to let us know if you have low blood pressure or low blood sugar, any inflammatory bowel diseases such as Crohn's disease or IBS, or asthma.

 *
Are you currently using any prescription medications or herbal supplements? If yes, please list them along with the name, dose, frequency of use, and condition being treated.This question is required.*

Psilocybin can interact with many prescription medications and herbal supplements. These interactions can be dangerous and/or reduce the subjective effects of psilocybin.

To ensure your experience at the Retreat is safe and positive, it's very important to let us know about any and all medications you're taking.

 *
We believe preparation and integration are important. Are you willing to commit to a preparation group zoom meeting and a post-integration group zoom meeting? (we will try to find a time that works for the majority) *
Dietary restrictions *
Within the house we will hold the retreat in, there will be different room options. Please indicate what room you would prefer. All prices in USD.  *
Required
Do you want to share a room with someone specific? Please state who below.  *
Please read the following and confirm you understand our cancellation policy. 

The deposit for the retreat is $500 USD. The full amount of the retreat is due by September 24th. There is no refund of the retreat investment after September 24th. 
 *
Please provide an emergency contact (name, relationship, phone and email) *
Do you have any questions or important  things to share with us?
Here is a beautiful image of the space we will spend so much time in. 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms