Retreat Registration Form

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YOUR DETAILS

Name *

Surname *

Date of Birth *

Gender you identify with *

Email *

Phone Number

Street Address *

City *

Post Code *

Country *

Profession, Work or Study *

Which retreat are you applying for? *

Netherlands: 31 Oct - 2 Nov 2025

Netherlands: March 2026

Netherlands: Summer 2026

Netherlands: Autumn 2026

Retreat for Artists & Creatives

What brings you to this retreat? Why are you interested in joining? *

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MEDICAL SITUATION

Have you ever had any of the following? *

Hyperthyroidism

Asthma or Chronic Obstructive Pulmonary Disease (COPD)

Autoimmune disease

Diabetes

Stroke

Epilepsy or Seizure disorder

Anaemia

Heart attack; failure or arryhthmia

Coronary heart disease

High blood pressure

Angina

Glaucoma

Liver disease

Kidney disease

Traumatic brain injury

NONE OF THE ABOVE

If yes, please say whether it’s in the past or still happening, how serious it is, and what treatment you’ve had.

Are you currently experiencing any of these? *

Dizziness

Heart palpitations

Panic attacks

Shortness of breath

Sleep difficulties

NONE OF THE ABOVE

If yes, please briefly describe what’s going on.

Are you currently pregnant or breastfeeding? Are you planning to have a child soon? *

Planning to have a child soon

Pregnant

Breastfeeding

NONE OF THE ABOVE

Do you take any of these medications regularly? *

Antacids

Antibiotics

Anti-depressant medication (SSRIs; SNRIs; MAOIs; Tricyclic)

Anti-anxiety medication

Blood pressure medication

HIV medication

Laxatives

Pain relievers

Sedatives

Sleeping pills

Stimulants

Steroids

NONE OF THE ABOVE

Please list all prescription medications you take. Include the name, dosage, and how long you’ve been taking them.

Do you take any of the following supplements regularly? *

5-HTP

CBD

L-Tryptophan

SAM-e (S-Adenosylmethionine)

St John’s Wort

NONE OF THE ABOVE

Please list any other supplements that you take on a regular basis.

Have you had any bad reactions to medicines or supplements? Please explain. *

Do you have any allergies, intolerances, or special dietary requirements? *

Briefly list any surgeries you’ve had and when. *

Briefly list any serious accidents, and when they happened. *

Have you ever been hospitalised for any other reason? Please give details. *

Have you been diagnosed with, or show signs of, any of the following conditions? *

ADHD or Autistic Spectrum (ASD)

Anxiety

Bipolar Disorder

Depression

Obsessive Compulsive Disorder (OCD)

Personality Disorder

Post Traumatic Stress Disorder

Schizophrenia or other psychotic condition

Substance use disorder or Addiction

NONE OF THE ABOVE

If yes, please describe what the diagnosis is, when it started, and how it affects you.

Has anyone in your immediate family (parents or siblings) been diagnosed with, or shown signs of, any of the conditions above? If yes, please say who, what the diagnosis was, when it started, and how it affected them. *

Have you ever had rage outbursts or acted violently towards yourself or others? Please explain. *

Have you had suicidal thoughts, or ever attempted suicide? Please explain. *

Are you currently seeing a doctor, therapist or other healthcare professional? Please say who and why. *

Is there anything else about your physical or mental health that we should know? *

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EXPERIENCE WITH ALTERED STATES

How often do you use alcohol, tobacco or cannabis, and in which situations? *

Have you ever used any of these psychedelic substances? *

Psilocybin / Psilcin (Magic Mushrooms)

LSD

Ayahuasca

DMT

5-MeO-DMT

Mescaline (Peyote; San Pedro)

MDMA (Ecstasy)

Iboga/Ibogaine

Ketamine

Salvia divinorum

Bufotenin (from toad venom)

2C-B (and related 2C compounds)

Other psychedelic (please specify)

NONE OF THE ABOVE

If yes, please list the substances, how often you took them, when in your life, the amount, and the purpose (e.g. recreational, therapeutic, ceremonial).

Have you used any of the following substances? *

Cocaine

Heroine or other non-prescription opiods

Fentanyl

Crystal Meth

Amphetamines (Speed)

Nitrous Oxide

GHB

Inhalants (glue; paint thinners; aerosols)

Synthetic cannabinoids (Spice; K2)

Synthetic cathinones

Other drugs/substances (non-prescriptive purpose)

NONE OF THE ABOVE

If yes, please give the name, how often, when in your life, the amount, and in what context.

Have you ever experienced any expanded states of consciousness without using substances — like through breathwork, meditation, fasting, or silent retreats? Please describe. *

Have you ever had a challenging or difficult experience during an expanded state of consciousness? Please describe, including what substance you took and what made it difficult. *

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PRACTICALITIES FOR THE RETREAT

We offer two payment groups.

> REGULAR

(€1250-1550)

The regular contribution for the retreat program. This rate is for those who have enough financial resources.

> SUPPORTER

(€1550-1900)

Your additional contribution allows us to offer retreats programs available at a lower rate for those with less financial resources.

We also have a few reduced-price spots for people on very low income. If you’re applying for a low-income spot, please contact us first and briefly explain your financial situation. These places are limited.

__________

According to the payment group you choose, please enter the amount you will be contributing. *

__________

Will you be responsible for your own retreat participation, or is someone else (like an organisation) paying or signing on your behalf? *

Myself

Someone else

If someone else, please write their full legal name.

__________

Please provide us with details for an Emergency Contact (not present at the retreat).

Name and Surname *

Type of relationship *

Phone Number *

I understand that this form contains sensitive personal data, including health-related information. By submitting this form, I give explicit consent for the collection, processing and storage of this data solely for the purpose of assessing my suitability for participation in the retreat. This data will be stored securely and retained for 5 years in compliance with GDPR requirements. I understand that I have the right to access, rectify or request deletion of my data as outlined in the Privacy Policy by using the contact details provided.

I consent to submitting the form *

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