Name
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First Name
Last Name
Email
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Phone
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Country
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Country of residence
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Which retreat dates are you interested in joining?
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What are you hoping to gain from joining Soul Medicine ?
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Do you have any previous experiences in working with psychoactive substances? Please share with us any experiences, dosage and what effect this experience had on you?
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Have you suffered from any physical or mental health conditions in the past? What is your overall health today?
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Are you currently using any medication?
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Please share with us what your current support network looks like: friends, family, therapist, coach etc.? Who can you speak to about this experience?
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Can you share information regarding your childhood; did you deal with any trauma (such as emotional or psychological abuse, physical or emotional neglect, divorce or separation of your parents, parent or guardians with addictions...)?
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Have you experiences trauma in your life otherwise? Such as natural disaster, accident, abuse, war zone... and how does this affect you now?
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Have you ever been diagnosed with any of these conditions or experienced these symptoms? Please mark accordingly.
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If you marked any of the above, please share some information about the past & current state of the disease/symptoms. If you selected "Other" or "Personality Disorder", please share more information about it below.
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Do you have any first or second-degree relatives with schizophrenia, bipolar disorder, or any other psychotic disorder? If yes, please provide details.
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Do you have any experience with holistic practices such as Yoga, meditation, Qi Gong etc? Do you have a regular practice?
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Anything else you would like to share with us to get to know you better?
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Do you sign and agree to the following statement?
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Wherein “I” refers to “You”, the participant of the retreat: “I am taking these psilocybin-containing mushrooms of my own volition. I acknowledge that no substance is entirely risk-free and that I am familiar and comfortable with the risks of psilocybin mushrooms.
I understand that the retreat is not intended as a substitute for medical or psychotherapeutic care.
I understand that I undertake other activities, including breathwork, dance, meditation, yoga, etc. at my own risk.
I have read and agree to the conditions with regards to your Covid and general cancellation policies.
I certify that all information provided on this form is true and complete. I understand that the admission to the retreat is based on some of the information provided on this form to ensure the safety of all participants and that any untruthful or inaccurate answers could lead to risks to myself or other participants.
Privacy Statement
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Your details, information entered and contact details are strictly confidential. They will only be kept within the Our Future Is Ancient organisation to decide on your suitability for our retreats. Choose yes if you agree to the storing and processing of your data.
Would you like to be added to our newsletter for exclusive community discounts?
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How did you hear about Our Future Is Ancient / Soul Medicine?
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If you are interested in our Valentines Love offer, please put the name of the second person
Instagram Handle
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