Lotus Vine Journeys Medicine of the Heart - November 8 -15, 2025 Application Form
We recognize that these are very personal questions however we need to collect this information in order to create a safe and healing retreat experience for all those who participate. Please note that we hold all the information disclosed in this Application with the highest respect and complete confidentiality. We are a multicultural community that is moving towards creating a more diverse and supportive retreat for everyone. Our retreats are specifically designed for those well-established on their spiritual path and for those who have a strong commitment to love, service, and liberation. The more honest you are in your disclosure, the more we can support your healing process during the retreat. Please take your time and answer each question as thoughtfully as possible. Thank you!
Email *
Full Name *
Age *
What is your ethnicity? Do you identify as a person of color? 
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Do you identify as: *
What is your preferred pronoun?
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Your email address
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Your phone number *
Where do you live? City - Country
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Have you been part of a Lotus Vine retreat? If so, when? *
Please describe your intentions and motivations for attending our retreat. What is your deepest intention and what do you want to heal? *
Could you please tell us about your occupation and the work that you do in the world? Include volunteering and other service work on behalf of all beings. *
Please describe in detail any previous experience that you have had with regards to working with plant medicines (Ayahuasca, Peyote, San Pedro, Mushrooms) *
Could you describe any spiritual practice you have done or currently undertake, yoga, or meditation? Do you maintain a practice on a regular basis? *
Have you attended a retreat or class with Spring Washam (The founder).   If so, when and where? *
Are you currently dealing with any physical ailments or do you have a physical diagnosis that you want to work on at the retreat? If so, please describe *
Do you have any of the following medical conditions?
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Required
Have you ever been in the military or police force? *
Have you been part of any extreme violent situation such as war, gang violence, others? *
If applicable, what mental health category would best describe your condition: *
If relevant, can you please provide some details around the extent of your mental health condition, when you were diagnosed and any medication that you currently take for it. *
Have you ever been hospitalized for a mental health problem? If so, please let us know when, and for how long. Please provide any additional information that we should know about the situation.*
Your answer
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Are you currently taking any type of medication? If so, please list the medications dosage and frequency taken. Please note that it is imperative that you list all medications, as the plant medicine can interact with certain medications in a way that can be dangerous.*
Your answer
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Have you ever taken SSRI (Selective serotonin reuptake inhibitors) medication for depression? If so when? For how long? *
Please select if you have you used any of these recreational substances in the past 6 months? *
Required
If yes, please describe context and frequency of use.
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Have you ever been a victim of physical or sexual abuse? We realize that this is a sensitive matter. It is important for us to know the extent and severity of these experiences so we can support you in the best way possible during your work with the medicine.*
Your answer
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Is there anything else you would like to share with the Lotus Vine Retreat facilitators at this time? *
Please provide us with an emergency contact. Please include name, phone number, email, and relationship. *
I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good. *
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