Integration Intensive 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
.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Preferred Pronouns
*
Do you have any specific questions about the program?
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.)?
*
Yes
No
If yes, what kind of non-ordinary states have you experienced and what was your experience like?
Have you had any significant traumatic experiences?
*
Yes
No
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 Name
Last Name
Emergency Contact Number
*
-
Area Code
Phone Number
Do you have any dietary restrictions?
Is there anything you would like us to know?
There is an opportunity to join a quarterly overnight Growth Group after this retreat, which will also use an IM ketamine experience - for ongoing personal integration and development. At this point, are you interested in such an opportunity?
Yes - definitely count me in!
No - not a fit for me.
Maybe - circle back to me post retreat please
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 attacks
Severe mental illness
High blood pressure
Past or recent physical injuries, including fractures or dislocations
Recent or current infectious or communicable diseases
Glaucoma
Retinal detachment
Epilepsy
Osteoporosis
Asthma (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 and Info:
The 3-day retreat is $1,195
Early bird discount of $100 if full payment is made by May 14th, 2025.
Payment and deposit instructions are provided after the application has been confirmed.
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
Retreat dates: August 15, 2025 to August 17, 2025
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 Name
Last Name
Date
*
-
Month
-
Day
Year
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.
Submit
Should be Empty: