Mezquita Psychedelic Retreats Screening Questionnaire
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At La Mezquita, we start your journey with an essential screening process, which is particularly important now as direct bookings are temporarily disabled. This initial step involves a questionnaire that helps us understand your medical background, previous substance use, and your goals for the retreat. By doing this, we can tailor your experience to ensure it is both safe and perfectly suited to your needs. This careful preparation is key to providing you with a transformative psychedelic experience.

Name *
Email
*
Gender - how you describe yourself.
*
What Experience are you interested in coming to?
*
What date is your treatment or retreat scheduled?
*
MM
/
DD
/
YYYY
Age *
MM
/
DD
/
YYYY
Telephone *
Country of residence
What Psychedelic substances do you have experience with? *
None
Tried it, less than 5 times
Experienced 5-20
Very experienced more than 20
LSD
DMT or Changa
Mescaline/San pedro
Ayahuasca
Mushrooms, Psilocybin
Others, Salvia Divinorum, Kratom...
With what intention did you take these substances? *
What, if any, of the following therapeutic or spiritual practices do you engage in to relax or connect with yourself? *
Required
Which, if any, of the following substances have you tried? (Optional) *
Required
Have you been using any of the above substances in the last 2 months? *
Over the last 2 months, how often have you been bothered by any of the following problems? *
0
1
2
3
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family?
Trouble concentrating on things, such as reading the newspaper or watching television?
Thoughts that you would be better off dead or of hurting yourself in some way?
Please indicate how much you agree with the following statements. *
Strongly disagree
Disagree
Slightly disagree
Mixed or neither agree nor disagree
Slightly agree
Agree
Strongly agree
I lead a purposeful and meaningful life.
My social relationships are supportive and rewarding.
I am engaged and interested in my daily activities.
I actively contribute to the happiness and well-being of others.
I am competent and capable in the activities that are important to me.
I am a good person and live a good life.
I am optimistic about my future.
People respect me.
Please answer the following questions? *
yes
no
Do you have or are you being treated for high blood pressure?
Do you have diabetes?
Do you use an Insulin Pump?
Do you have an irregular heartbeat (such as “afib”) or heart rhythm problem?
Have you ever attempted suicide?
Have you ever had a heart attack?
Have ever had a major operation?
Have you ever had any blockages in your neck, head or legs of mayor arteries? Peripheral vascular disease (PVD)?
Do you have any health issues? Either mental or physical health? Please explain in detail... *
Have you ever been  hospitalized in a mental health facility, either voluntarily or involuntarily? *
Do you have a family history of mental health issues? Bipolar, Psychosis, schizophrenia? *
Do you currently take any prescribed medication? *
Please list your medication and doses, and briefly describe why you take it.
Do you follow any of the these dietary restrictions? (Please select all that apply.) *
Required
Do you have any food allergies? (e.g. gluten free, peanut free)
*
Are you allergic to chocolate?
*
Required
Are you allergic to cats? We have a cat, if this is a problem for you, maybe consider not booking.
*
Required
Is there anything else you think we should know?
What are your motivations for doing this experience? *
After completing this questionnaire, please schedule a 15-30 minute screening interview with us so that we can properly prepare you for the experience, gather some more information from you, and answer any questions you may have before embarking on your psychedelic journey. Please use this link to schedule: https://calendly.com/mezquitaalicante

Note that we will not be able to guarantee your spot at this retreat if you do not schedule an interview.  

Did you request a calendly meeting?
*
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