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Application for CFIR Men's bogaine Retreat
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Email *
Name *
Address *
How did you hear about the Center for Intimacy Recovery's retreat? *
What is the reason(s) you would like to participate in this retreat?
What would be your ideal outcome from this retreat? *
If you are in a relationship, please describe the nature of the relationship and months or years together.
Describe your current living situation. Do you live alone, with others? With family, etc...
Do you have children? *
Are you currently seeing a mental health care professional?  *
If you are seeing a mental health care professional, please provide their name and contact information.
Frequency of therapy.
Do we have permission to contact your mental health provider? Would you like us to in order to coordinate care with them? *
Who is your primary care physician? Please include type of MD, name and phone number. *
Specify all medications and supplements you are presently taking and for what reason. *
If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.
Do you drink alcohol? *
Do you use recreational drugs? *
Please describe any history of substance abuse including types of drugs, first time used, last time used, and route of administration.
Do you have an addiction to sex, gambling or food? Please elaborate. *
Have you ever been involved in 12 Step Recovery? *
Do you have suicidal thoughts? *
Have you ever attempted suicide? *
Do you have thoughts or urges to harm others? *
Have you ever been hospitalized for a psychiatric issue? *
Is there a history of mental illness in your family? *
 What is your support system like? *
What is your level of education? Highest grade/degree and type of degree. *
What is your current occupation? What do you do? How long have you been doing it? *
Please check any of the following you have experienced in the past six months.
Please check any of the following that apply:
What are you current life stressors? *
What else would you like to share? *
If you have had any previous experiences with psychedelics please share it here, including: the substances used, how often and when was the last time, was the setting therapeutic or recreational. What was your outcome like? Positive? Negative? *
Do you have a current valid passport? *
Emergency Contact Person: *
Emergency Contact Person Phone Number and Email: *
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