Application
Thank you for applying for the Primal Shamanic Medicine Retreat with Activate Your Alchemy. As this is a very powerful and intimate experience, we ask that you please fill out the application below so that we may understand your intentions for attending this retreat, and decide if it is right for you and us. 
Sign in to Google to save your progress. Learn more
Email *
Your Full Name *
Birthdate *
MM
/
DD
/
YYYY
Address (Street, City, State) *
Mobile Number (please include area or country code) *
What is your profession?
Briefly explain why you feel called to this experience. What are your intentions for participating? What do you hope to achieve? *
What are your main life challenges, blocks, traumas, etc.? *
Do you have any regular personal development, spiritual, or physical practices you do? (yoga, meditation, coaching, therapy, etc.) If so, please briefly explain. *
Do you have any prior experience with "etheogenic" (psychedelic) plant medicines, or have you ever attended a plant medicine retreat?  *
If yes, was this recreational use or in a ceremony/retreat setting?
Clear selection
If yes, which medicines?
Are you currently taking any pharmaceutical and/or herbal medications? If yes, please list name and dosage (if none, write "none") *
Have you or your family members ever been clinically diagnosed with any of the following?*
 *
Required
If yes, please indicate who was diagnosed and when.
Do you suffer from any addictions (alcohol, drugs, eating, sex, etc.)?
 *
If yes, please describe:
Do you have any physical impairments we should be aware of? This includes recent heart attacks, stroke, blood pressure, major surgeries, diabetes, disabilities, etc.
 *
Do you have asthma or other breathing difficulties? *
If yes, do you use an inhaler or other medication? Please list frequency and dose.
Do you suffer from Crohn's disease or gastric ulcers? *
Do you have any known allergies?
Clear selection
If yes, to what?
Do you have any chronic illness? *
If yes, please describe
Do you use stimulants and/or drugs? This includes things like coffee, cannabis, MDMA etc. If so, which and how often? *
Are you currently taking any medication for any psychiatric disorder? *Antidepressants or other: Prozac, Seroxat, Zoloft, Effexor, Paxil, Welbutrin (bupropion),Zyban ,Pristiq, Cymbalta, Ixel, Effexor, Tramadol, Tramal, Ultram, Sibutramine, Meridia, Reductil, Axiomin, Etonin, Lubazodone, Serzone, Nefadar, Trazodone, Desyrel, Strattera, Edronax, Vivalan, Focalin, Ritalin, Concerta, Adderall, Dexedrine, Desoxyn, Vyvanse, Elavil, Endep, Evadene, Clomipramine,Anafranil, Desipramine (Norpramin, Pertofrane), Amoxapine (Asendin), Maprotiline (Ludiomil), Mianserin (Bolvidon, Norval, Tolvon), Mirtazapine (Remeron), Isocarboxazid (Marplan), Moclobemide, Aurorix, Manerix), Phenelzine (Nardil), Pirlindole (Pirazidol), Selegiline , Eldepryl, Zelapar, Emsam, Tranylcypromine (Parnate), Lithium, or other
 *
If yes, reason for medication and dosage.
Have you ever experienced seizures or been diagnosed with epilepsy? *
Do you go to therapy, or are you in a support group? If so, please describe. *
Do you have any resources for integration/support after working with this medicine? If so, please describe (we can also provide you resources if you don't) *
Are you pregnant? *
Are you breast feeding? *
Any additional medical and/or other personal information you would like to make us aware of? This includes any dietary restrictions. 
 *
Anything else you'd like us to know?
Please Note:
Once your application has been submitted, we will review it and get back to you, usually within 1-3 days. If accepted, we will send you a payment link. Payment is due immediately in full in order to reserve your spot. We try to keep our retreats small, so space is limited. 

If any questions or concerns arise from your application, we will reach out to you for clarification. Should you have any questions in the meantime, please feel free to contact us at adamshiva.aya@gmail.com

*By submitting this application, you certify that you have answered all questions accurately to the best of your ability. You also understand and agree that neither the facilitators nor assistants of Activate Your Alchemy are doctors or medical professionals, and our review of your health screening in no way indicates medical advice or approval. Furthermore, you understand that facilitators are acting in a "harm reduction" role during any sessions that may take place. Please check with your doctor if you have concerns.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms