Name
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First Name
Last Name
Email
*
Phone
Country
(###)
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Which retreat(s) are you interested in?
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Do you have experience with plant medicines / hallucinogens? Yes No; if yes which one? And when was your last journey with which substance (approximately)?
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Do you have experience with breathwork, meditation, body-oriented work, body-oriented coaching, yoga, conscious dance, tantra, or other awareness-broadening or personal growth-oriented practices? Yes No; if yes which one?
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Do you have specific alergies?
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Are you currently being treated by a psychiatrist/psychologist/coach or medical doctor (if so, for what and what kind of treatment, since when)?
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Have you, or someone in your immediate family (such as a parent, sibling, or child), ever been diagnosed with any of the following conditions?
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Do you currently use any medicines or (nutritional) supplements (if so, which ones and for what)?
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Have you taken any medications in the past? If so, how long ago, type of medication and what was it for?
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Do you have heart problems or high blood pressure or an illness at the moment (or in the past year) of which it is necessary for us to know because of your own safety?
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Do you ever or regularly use alcohol, Ecstasy, marijuana or other substances? If so, which ones and how often?
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Are you vaccinated against Covid 19? If so, on what date did you receive your last vaccination? (if this is within 3 weeks of the ceremony date you cannot participate due to possible interactions)
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Do you want to write something about the specific issues that you constantly encounter for yourself; what are your recurring themes?
What would you like to explore about yourself in the retreat(s)?
What would you like to explore about yourself in connection with others in the retreat(s)?
What would you like to leave behind in the retreat(s)? (something that no longer serves you)
And what would you like to attract and open to in the retreat(s)?
Thank you for your submission!
We’re happy you’re interested in joining us. We’ve received your form, and we appreciate the care and openness with which you shared your information.
Because we work with plant medicine, we use your submission not only for registration but also to get a sense of whether this retreat is a good match for you. Please know that all information you provided is strictly confidential and will only be used in preparation for the retreat(s) mentioned in your form.
We strive to review your submission within 3 working days. You can expect a message from us via WhatsApp or SMS if you provided a phone number, or via the email, to set up a date for your intake call.
Warm regards,
Ioana and Imke
