F.I.V.E Retreat Vetting

F.I.V.E
5-MeO-DMT Information & Vital Education

Retreat Vetting Form
All information disclosed within this form is confidential and will not be shared with anyone outside of F.I.V.E.

Please do not leave any field blank. If there is nothing to write in that feild write N/A.
Date

Month Day Year
Date
Personal Name

First Name Last Name
Retreat Details

Retreat Company Name Location of Service
Website Links

Website Secondary Website
Social Links

Facebook Instagram
Retreat Facilitators

Please list all staff serving 5-MeO-DMT at your retreats. Facilitators may be contacted for interviews.
Facilitator Name #1 (Owner)

First Name Last Name
Number of years serving
Email
example@example.com
Phone Number
Please enter a valid phone number.
First Aid Certificate

Cancel of
Facilitator Name #2

First Name Last Name
Number of years serving
Email
example@example.com
Phone Number
Please enter a valid phone number.
First Aid Certificate

Cancel of
Facilitator Name #3

First Name Last Name
Number of years serving
Email
example@example.com
Phone Number
Please enter a valid phone number.
First Aid Certificate

Cancel of
Facilitator Name #4

First Name Last Name
Number of years serving
Email
example@example.com
Phone Number
Please enter a valid phone number.
First Aid Certificate

Cancel of
If there are more than 4 facilitators serving 5-MeO-DMT on your team please list them here including their names, emails and phone numbers.
Is your retreat in a country where 5-MeO-DMT is NOT ILLEGAL?

Yes No
Has your retreat had any claims of malpractice or complaints within the community? If yes, please explain:
Has anyone in your retreat team ever been convicted of a sexual abuse? If yes, please explain:
Has anyone been physically or mentally harmed after sitting at your retreats? If yes, please explain:
Do you serve other medicines alongside 5-MeO-DMT in your retreat container? If so, please explain:
Please explain your retreat dosage protocols when working with participants:
How many participants does your retreat take at one time?
What are your safety protocols to keep participants safe at your retreats?
What is your emergency protocol during a retreat should something happen to a participant?
What is your retreats preparation protocol?
What is your retreat's integration protocol?
When hiring retreat facilitators what is your criteria?
Are your all of your facilitators first aid certified?
Describe the style of the retreat container:
Please describe your detailed protocol write up. What does a participants process look like from start to finish. Be as detailed as possible.
What additional trainings or credentials do your staff have to support retreat participants? What additional practices are done during the retreat alongside medicine?
Facilitator References

Please Include two facilitator references within the 5-MeO-DMT community. References will be contacted.
Facilitator Reference #1 Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to reference
Facilitator Reference #2 Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to reference:
Participant References

Please Include four references of participants who have sat with you recently. References will be contacted.
Participant Reference #1 Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to reference:
Participant Reference #2

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to reference:
Vetting Material Uploads

Please upload all information that gets sent to your participants.
Preparation Information

Cancel of
Additional Preparation Information

Cancel of
Integration Information

Cancel of
Additional Integration Information

Cancel of
Medical Screening Form

Cancel of
Photo of ceremonial space

Cancel of
Photo of retreat centre

Cancel of
If there are any additional materials including materials that you had a difficulty uploading please send them here: info@five-meo.education

To complete your application submission:

-Please send your $350 application fee via paypal to:

paypal.me/KaivalyaVenturesInc

Note: The above fee pays F.I.V.E. review panelists during the final step of the vetting process. If you do not have a paypal account, please email us and we will send you a personal invoice.

Once F.I.V.E has reveiwed your submission via your intake form and email including the above information, our team will be in contact with you to schedule your live video call with a panel to go over your process.

Thank you for your submission, we will be in touch shortly!
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F.I.V.E

5-MeO-DMT Information & Vital Education

Retreat Facilitators

Facilitator References

Participant References

Vetting Material Uploads