Eligibility Questionnaire
This is the first step in the reservation process. Please fill out the form. After it is reviewed we
will contact you via video call on a platform such as Zoom or Skype. Thanks!
Email address *
Briefly describe why you are drawn to participating in a medicine retreat *
Your answer
What is your previous experience with plant medicine or psychedelics *
Your answer
Do you currently have any self care tools such as yoga, meditation, dance etc.? *
Your answer
This retreat will include elements of prayer, and intention please describe your experience ofspirituality and openess to spiritual practice *
Your answer
Current health concerns or relevant physical health history *
If yes, please describe
Your answer
Are you currently taking any medications *
Do you have an environmental allergies? *
If so how do you manage them?
Your answer
Do you have any dietary concerns or food allergies? *
If so, please describe
Your answer
Do you or any family members have a history of mental illness, suicide or suicidal ideation? *
Do you have a history of psychological or sexual trauma? *
Have you ever travelled outside of the United States? *
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