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29th March 2025
Name
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Email
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Date Of Birth
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Phone Number
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Full address including post code
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Health Information
Do you have any pre existing medical conditions?
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Yes
No
If yes please specify
Are you currently taking any medications?
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Yes
No
If yes please specify
Do you have any known allergies?
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Yes
No
If yes please specify
Mental health conditions/history
Do you have any mental health conditions, such as PTSD, anxiety, depression or other?
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Yes
No
If yes please specify
Are you currently receiving any treatment or therapy for mental health conditions?
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Yes
No
If yes please specify
Do you have any history of traumas or significant life events?
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Yes
No
If yes please provide a brief explanation
Experience with Psychedelics
Have you had any experience with Psychedelics such as LSD, psilocybin mushrooms or ayahuascha?
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Yes
No
If yes please specify
Have you had a positive or negative experience with psychedelics?
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Yes
No
Please give more details
How recent was your experience? Please provide approx dates
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Did you have any specific goals intentions for your previous experience?
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Yes
No
If yes please provide details
Have you experienced any significant anxiety or panic attacks in the past?
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Yes
No
If yes please provide details
Are there any specific triggers or situations that tend to cause anxiety for you?
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Retreat activities 121 setting
121/duo retreat only Have you got a safe space free from distractions?
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Yes i have a safe space free from distractions (family/pets)
No, please discuss options with me
Are you comfortable participating in outdoor activities?
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Yes i have a safe space free from distractions (family/pets)
No, please discuss options with me
N/A
Are you comfortable participating in group activities? (Group retreats only)
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Yes
No
N/A
Do you have any physical limitations or disabilities that may effect participation in certain activities?
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Yes
No
If yes please specify
Emergency contact details
Please provide below emergency contact details
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Name, Phone number and relation
By signing below, I acknowledge that I have read and understood the information provided in this health and safety checklist form, and I hereby confirm that all the information provided is accurate and complete to the best of my knowledge. I understand that a face-to-face or video call will be required to further discuss my suitability for the retreat at this time. During this call, we will also discuss intentions, as they play a crucial part in the retreat experience. Additionally, I acknowledge that integration after the retreat is paramount to the overall experience.
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Please Print Full Name and Date
Protocol Adherence and Right to Refuse Attendance For the safety and well-being of all participants, strict adherence to our pre-retreat protocol is mandatory. This protocol includes a specific dietary regimen as well as the complete abstention from certain substances, whether prescribed or non-prescribed, leading up to the retreat.Failure to comply with these requirements may pose serious risks not only to your own safety but also to the safety of others during the retreat. As a result, we reserve the right to refuse your attendance at the retreat if it is determined that you have not fully adhered to the protocol.Please be aware that if you are refused entry to the retreat due to non-compliance with these guidelines, you will not be eligible for a refund. It is imperative that you take these preparations seriously to ensure a safe and transformative experience for everyone involved.
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Please sign name below
Plant Medicine Retreat
Please note that the information provided in this form is confidential and will be used solely for the purpose of ensuring your safety and well-being during the plant medicine retreat.
Cancellation Policy
We pour our heart and soul into creating these beautiful retreats, ensuring every detail is aligned to provide deep transformation, connection, and healing. Due to the time, effort, and resources that go into planning each experience, our cancellation policy is as follows:
🔸 Cancellations within 30 days of the retreat – No refunds will be given.
🔸 Cancellations between 30-60 days before the retreat – 50% of any payments made will be retained, plus the non-refundable deposit.
🔸 Cancellations before 60 days – A refund will be issued minus the non-refundable deposit.
This policy is in place because spaces are limited, and cancellations impact the retreat in many ways. As soon as you book, we begin making arrangements—from securing venues and facilitators to preparing resources and materials, all of which require upfront costs. Last-minute cancellations also make it difficult to fill the space, as these retreats are deeply intentional and require preparation for those attending.
💫 Please note: This cancellation policy is outlined in the health form, which is completed at the time of booking. By submitting the form, you acknowledge and agree to these terms. Thank you for your understanding and for honoring the energy, time, and love that go into creating these sacred experiences. 💛
I agreed with Cancellation Policy
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Yes
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