Practitioners Experiential Integration Retreat

Practitioners Experiential Integration Retreat Application

Thank you for your interest. Please complete the following application and press "submit" at the end. Your responses will be kept confidential and only shared with the retreat organizers.
To view the retreat information page with all details, click here for Big Sur or click here for Nevada City.
Name*

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Email*
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Profession*
Address

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Gender*
Preferred Pronouns*
Do you have any specific questions about the program?
Which retreat dates are you available for? Select all that apply.*

January 30, 2025 - February 3, 2025 (Nevada City, CA)May 1, 2025 to May 5, 2025 (Big Sur, CA)July 24, 2025 to July 28, 2025 (Big Sur, CA)September 4, 2025 to September 8, 2025 (Big Sur, CA)
Do you have a first choice on a retreat date above? If so, please specify.
Are you interested in earning 40 hours of continuing education (CE) credits for an additional fee of $99? (See the website for more information. CE is offered under the American Psychological Association)

NoYesNot sure yet
Do you have any dietary restrictions?
Have you had any training in psychedelics?
Have you experienced non-ordinary states (psychedelic experiences, dreams, shamanic drum journey, vision quests, Holotropic Breathwork, mystical experience etc.)?*

YesNo
If yes, what kind of non-ordinary states have you experienced and what was your experience like?
Have you had any significant traumatic experiences?*

YesNo
If yes, what are the basic events and estimated dates?
Please describe your prior involvement with groups and the role you find most comfortable in a group setting.*
What drew you to this experience and what do you hope to get out of it? *
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

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Is there anything you would like us to know?
Breathwork Questions
Have you participated in breathwork before and if so, what kind and what was your experience?*
Do you have a history of, or currently experience any of the following: (please estimate date or ongoing)*

Cardiovascular disease, including heart attacksSevere mental illnessHigh blood pressurePast or recent physical injuries, including fractures or dislocationsRecent or current infectious or communicable diseasesGlaucomaRetinal detachmentEpilepsyOsteoporosisAsthma (If yes, please bring your inhaler to the workshop.)Have you ever been hospitalized for medical reasons?Are you currently pregnant?Have you been through a spiritual or emotional experience/emergence that prevented you from functioning in your daily life?None of the above
If you answer “yes” to any of these questions, please explain or elaborate. This form is confidential.
Informed Consent Questions
Please read and check the items below to give consent.*

I acknowledge that this retreat is experiential and educational and is not psychotherapy.I acknowledge Jennifer Allen and/or Michael Beck are in roles of group facilitation. Jennifer is working under the role of licensed psychotherapist and Michael Beck of a licensed psychologist.I understand their roles in this group are not substitutes for ongoing 1:1 therapy support which is highly recommended.I acknowledge that there may be a "trainee" present, supporting the group and bound to confidentiality.I commit to paying the agreed on fees by the due dates.
Pricing Options:
- The 5-day retreat is $1,890
- Payment and deposit instructions are provided after the application has been confirmed.
- Complete payment is due 2 months prior to the retreat start date.
- Ketamine Medical Provider's charge is separate ($375 additional fee).
- Earn 40 hours of continuing education (CE) credits ($99 additional fee, optional).
PLEASE READ AND SIGN THE FOLLOWING STATEMENT. I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good. By printing your name and date below you are providing your signature and your informed consent. *

First NameLast Name
Date*

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Date
Thank you for applying! You will receive an email from the retreat organizers with answers to your questions or next steps for joining the retreat.
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Practitioners Experiential Integration Retreat Application

Breathwork Questions

Informed Consent Questions

Thank you for applying! You will receive an email from the retreat organizers with answers to your questions or next steps for joining the retreat.