Application Form

Sacred Soul Awakening Retreat

First Name *

Last Name *

Email *

Age *

Allergies *

Please list your allergies separated with commas. If you don't have any, just enter "None"

Have you ever been diagnosed or suspect you have any of the following medical conditions? *

High blood pressure

Heart attack

Heart arrhythmia

Stroke

Heart failure

Coronary artery disease

Chest pain or angina

Epilepsy or seizure disorder

Currently pregnant or breastfeeding

Liver or kidney failure

Cancer

Diabetes

Asthma or COPD

Traumatic brain injury

None of the above

Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions? *

Depression

Anxiety

Post Traumatic Stress Disorder (PTSD)

Attention Deficit Hyperactivity Disorder (ADHD)

Substance Use Disorder or Addiction

Obsessive Compulsive Disorder (OCD)

Schizophrenia or other psychotic condition

Bipolar disorder

Personality disorder

Other

None of the above

Have you used any of the following substances in the past 3 months? *

Cocaine

Methamphetamine

Heroin or non-prescription opioids

Inhaled nitrates

GHB

Cannabis

None of the above

Past Psychedelic Use

Desired Outcomes from Psychedelic Use *