Retreat Application- Fall 2025

Gay & Queer Men’s KAP Retreat Interest Form

Upcoming Retreat Dates Coming Soon!
Welcome to the application for our Gay & Queer Men's Fall Retreat by Prism Collective!

This application will allow us to gather important information about you as it relates to your unique retreat experience. The second section of this application will collect information about your preferred accommodations and outlines the payment schedule.

Pricing for this inclusive 4 night retreat is $3000. Single rooms are $3300.

Please contact our office at Health@myhealth101.org with any questions.

Once the application is received, one of our practitioners will be in touch with you to schedule your telehealth screening appointment.
Psychedelic Experience Intake Form

The questions in this section will gather some basic information about you
Name*

First NameMiddle NameLast Name
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
DOB*

MonthDayYear
Date
Gender
Do you identify with any sociocultural subgroups? If so, please specify
BIPOC, LGBTQIA+, etc.
Height (inches)
Weight (pounds)
Health History

The questions in this section will gather information about your mental and physical health
Date of last physical

MonthDayYear
Date
Date of last EKG

MonthDayYear
Date
Are you allergic to anything?*
Please provide a description of the allergy or intolerance as well as reaction you have below. Type N/A if you're not allergic to anything.
High blood pressureHeart attackHeart arrhythmiaStrokeHeart failureCoronary artery diseaseChest pain or anginaEpilepsy or seizure disorderCurrent Pregnant or BreastfeedingLiver or kidney failureCancerDiabetesAsthma or COPDTraumatic Brain InjuryNone of the aboveThyroid ConditionInsomniaUnderweightOverweight/ObesityOther
Description of medical condition(s)
Please use this space to FURTHER DESCRIBE medical conditions from the previous page. Information on how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc. is welcome.
DepressionAnxietyPost Traumatic Stress Disorder (PTSD)ADD/ADHDSubstance Use Disorder or AddictionObsessive Compulsive Disorder (OCD)Schizophrenia or other psychotic conditionBipolar disorderPersonality disorderEating Disorder (Anorexia, Bulimia, Binge eating disorder)None of the aboveOther
Description of psychiatric condition(s)
Describe any PTSD or cPTSD symptoms
PTSD-like symptoms tend to be brought to awareness through psychedelic use. Could it be that you have any PTSD symptoms or experiences? Consider cultural trauma, ancestral trauma, birth trauma, & current lifespan trauma. If so, please elaborate.
Description of psychiatric hospitalization(s)
Description of suicidal thoughts or attempt
Description of self injury behavior
Cutting, head banging, stabbing, swallowing or inserting object, etc.
Prescription medications
Please include a complete list of your prescription medications including the drug NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
OTC medication, supplements, and herbal products
Please include a complete list of your OTC medication, supplements, and herbal products including the NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
If there are any other files or medical records you feel are relevant please upload them here.

Blood Work results, ECG, physical, psychiatric or therapy notes or assessments, etc.
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Substance Use

The following questions are designed to understand more about your history and relationships to various substances
1 drink per month or less1 drink per week or lessA few drinks per weekA few drinks most daysSeveral drinks most daysSeveral drinks every day
Further Description of Alcohol Use
Further description of tobacco use
CocaineMethamphetamineHeroin or non-prescription opioidsInhaled nitratesGHBCannabisNone of the above
Further description of substances used:
How much of each substance? How often? Any additional commentary you wish to offer.
Description of Past Psychedelic Use
Please describe the use and experiences with previous psychedelics.
Intention for Psychedelic Use*
Please describe why you would like to undergo a psychedelic experience including why you want to use any specific psychedelic and why you feel using it at this point in your life would be beneficial?
Desired Outcomes from Psychedelic Use*
Please describe what you are hoping to receive from psychedelic use, what insights you hope to gain, What answers are you hoping to receive? What changes are you hoping to become able to implement in your life? How do you desire to feel or act differently than now?
Please take some time to describe your personal mythos & experience of childhood:
What do you hold, were told, feel and remember from your ancestors?
Do you feel you carry a particular legacy or were given a mission?
Do you have any concerns or fears about what might come up during your Psychedelic Experience?*
Questions or topics for discussion*
Please use this space to type any specific questions you may have about current medications or substances you're taking or about psychedelics you're interested in or plan to take.
Social History and Support Network

The following questions will help understand more about your current social situation and support network
SingleMarriedMarried with ChildrenSeparated or DivorcedWidowedDomestic PartnerLong-term relationshipOther
Please describe your current relationship
Unable to work due to disabilityNot working by choiceUnemployed or underemployedStudent or education programPart timeFull timeRetiredOther
Have you ever had any legal problems? Please elaborate.
Are there any major sources of stress in your life at the moment or events that have occurred recently that have impacted your health?
E.g. Workplace struggles? Toxic relationships? Death of persons close to you? Change in health status? Ongoing stressors? etc.
Therapist or CounselorPsychedelic Integration CoachPsychiatrist or ProviderAlternative PractitionerPartner or Family MembersClose FriendsPsychedelic SocietyChurch or Religious OrganizationTreatment ProgramOther
Please elaborate about your support network *
How can they be involved post-ceremony?
With whom in your support network can you share your Psychedelic Experience?
Please name and list them and make a note of your relationship to them; Example: Seth (brother) Mary (Therapist) Suzanne (close work colleague): we've known each other for 15 years.
Current Symptoms

The following questions are designed to create a snapshot of how you've been feeling over the last 2-4 weeks

Survey of Depression Symptoms*

Rows	Not at all	Several Days	More than half of days	Almost every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

Survey of Anxious Symptoms*

Rows	Not at all	Some of the days	More than half of days	Almost every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Stressful Life Experience and Trauma Symptoms*

Rows	Not at all	A little bit	Moderately	Quite a bit	Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Feeling very upset when something reminded you of a stressful experience from the past?
Avoided activities or situations because they reminded you of a stressful experience from the past?
Feeling irritable or having angry outbursts?
Feeling jumpy or easily startled?

Submission

Congratulations! Almost there. These last few questions will allow us to learn more about who you are and anything else you'd like to mention.
Please describe yourself*
How would others describe you?*
What are your strengths?*
What are you passionate about?*
What are your perceived weaknesses?*
Is there anything else you'd like to mention?
Accommodations

Easton Mountain offers two options for accommodations (listed below). Please select your accommodation preference below.
Single Occupancy $3000Double Occupancy $2700
Payments

Please review and agree to Terms & Conditions, including payment schedule, below.
Please complete credit card authorization via the secure form linked here.

If the above link does not open, please go to: https://goetzel.medforward.com/FillOutForm.aspx?formname=Credit_Card_Form

AS FOR COSTS/FEES/PAYMENTS I agree to:

3 payments automatically deducted from my credit card (on file).

Single Occupancy: $3000 total / $1000 each payment

Double Room: $2700 total / $900 each payment

FIRST PAYMENT due at sign up. Reserves my space in the program and meeting with one of our clinicians. First payment is fully refundable up to the day of the screening meeting and in case any medical contraindications for KAP are discovered during the meeting.

I understand and agree that starting with the day after the screening meeting, this first payment is to pay for my medical screening meeting and secures my spot at the retreat and is therefore non-refundable.

SECOND PAYMENT will be automatically deducted from credit card on file on file 60 days before the start of the retreat or the day after your screening meeting, as discussed.

I understand that this payment secures my spot at the retreat and is non-refundable.

THIRD PAYMENT is due 30 days before the start of the retreat and is automatically charged to the credit card on file.

I understand that this payment secures my spot and is non-refundable.

I understand that it is my responsibility to keep a valid credit card with proper funds on file so that later payments can be deducted. I understand that if later payments cannot be received according to the schedule, there will be no refund for previous payments, and I will lose my spot to the next on the waiting list.
Signature
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Gay & Queer Men’s KAP Retreat Interest Form

Psychedelic Experience Intake Form

Health History

Substance Use

Social History and Support Network

Current Symptoms

Submission

Accommodations

Payments