Application Form

Name

Surname

Phone Number

Please tick which ones apply to you.

Medical heart condition

Pregnant or breastfeeding

Taking anti-depressive medication

Borderline Personality Disorder diagnosis

Psychosis; Schizophrenia; or Bipolar Disorder

NONE OF THE ABOVE

Which retreat are you applying for?

Psilocybin Retreat in the Netherlands

Retreat for Artists & Creatives

Retreat for LGBTQIA+

Are there any specific retreat dates you are interested in?

How did you hear about us?

Is there anything currently holding you back from moving forward with the retreat application, or that you're unsure about?

Cost of the retreat

Timing of the retreat

Something on the medical checklist above concerns me

Not sure this retreat is the right fit for me

Waiting to talk to a partner; family; or therapist first

Nervous about the experience itself

Nothing – I'm ready to go

Other (please fill in the reason below)

Other

By submitting this form, I confirm that I have read and understood the Privacy Policy and consent to the collection, processing and storage of my personal data for the purposes of the retreat. My data on this form will be stored securely and retained only until the end of the retreat program. I understand that I can withdraw my consent at any time by using the contact details provided.

I consent to submitting the form.

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