EPIC / Radiant Heart Retreat Application

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Email *

First and last name *

Home city and state *

Phone number *

Date of birth *

YYYY

How did you hear about our retreat offerings?
*

What are your current medications and supplements?
*

Please describe any mental health challenges you have
*

Please describe any physical challenges you have
*

Do you have experience with psychedelics and/or other altered states of consciousness? If so, please describe
*

What draws you to group work with psilocybin?
*

Have you attended a retreat before? If so, please describe
*

Which type of retreat would you like to attend?
*

Women only

Men only

Coed

Please let us know if you're interested in any particular one(s) of our upcoming retreats

Would you be interested in staying at the retreat house where events will be held, or having separate lodging?
*

Retreat house

Separate lodging

Other:

Please describe your current support system and self care practices *

Do you have dietary restrictions? If so, please describe
*

Is there anything else we should know?
*

A copy of your responses will be emailed to the address you provided.

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