Language
English (US)
Español
Sacred Life and Subtle Winds March Group Psilocybin Journey
March 27th-March 30th Fern Love Service Center Forest Grove OR
Name
E-mail
Phone Number
-
Area Code
Phone Number
Tell us a little about your self and what brings you to this space
*Please note that our lead facilitators will follow up with you to do a deeper and more formal screening and preparation call
What best describes the reason for your interest in joining this group retreat
Self Improvement
Spiritual Work/Ceremony
Physical Wellness and Healing
Emotional/Mental Wellness and Healing
Curiosity
Other
The Why?
Please review the safety and screening outline below first and then answer the following questions.
What is something that you are hoping to work on or focus on as your intention for this journey.
Will you be 21 years or older by March 1st 2025
Yes
No
Do you have previous experience with psychedelics?
Yes
No
Have you taken the Prescription drug Lithium
Yes
No
Have you ever been diagnosed with active psychosis or treated for active psychosis.
Yes
No
Have you ever been diagnosed with schizophrenia or bipolar 1?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Do you have a heart condition, epilepsy, or history of aneurysms?
Yes
No
Are you currently begin treated by a medical, behavioral health, or other health care provider for a condition?
Yes
No
Are you currently taking any medications that might need to be consumed before/during a psilocybin administration session?
Yes
No
If yes, what medications?
Safety and Screening
Below are potential rule outs and may exclude you for ketamine: 1. Pregnant women or nursing mothers: The effects of ketamine on pregnancy and the fetus are undetermined and it is advisable to protect against pregnancy while exposing yourself to ketamine or in the immediate aftermath of its use. Nursing mothers will need additional assessments and coordination of care before being considered for eligibility. 2. Untreated hypertension and/or History of certain types of unstable heart disease, including but not limited to arrhythmias, congestive heart failure, coronary artery disease. 4. History of a bladder transplant or significant bladder/urinary problems. 5. Untreated sleep apnea or severe sleep apnea where a CPAP is required. 6. Allergy to ketamine or esketamineor adverse reactions to anesthesia. 7. Current or past problems with laryngospasm and throat closing. 8. Concerns for habitual use of ketamine, ketamine analogs, or alcohol/benzodiazepine or other substance use with concerns for serious withdrawals when abstinent (severe tremors, seizures, hallucinations, etc. 9. Body Mass Index (BMI) below 16.5 10. History of psychosis or mania requiring hospitalization or certain other behavioral health concerns 11. Untreated hyperthyroidism and certain immunocompromised conditions
Do you have any medical conditions or medications that you want us to know about before your formal screening with our provider.
Are you on any current medical or mental health medications? If yes, can you list them here.
I have read the above safety and screening guidelines and answered the above questions honestly. Please Sign Here.
Today's Date
-
Month
-
Day
Year
Date
The Journey Begins
The cost of the Retreat is $365. You will receive an email back to set up a time for a introduction call once you have completed this form.
Any other comments or questions that we can address?
Submit Sign UP
Submit Sign UP
Should be Empty: