Sacred Mushroom Journey 9/23

We are so excited to share this retreat space with you!

We want to get some basic information to make sure that we are providing the most safe and supportive experience for you. All of the info on this form will be kept confidential.

We will have a 30 minute intake video call once you've completed this form to connect and get to know one another.

Full Name*

First NameLast Name

What is your age?*

Contact Number*

Email Address*

example@example.com

Emergency Contact Name*

Emergency Contact Phone Number*

xxx-xxx-xxxx

Emergency Contact Email*

example@example.com

What drew you to this retreat experience? What motivation/intention do you bring?*

Have you had psychedelic experiences before?*

YesNo

If so, please describe what psychedelics you've experienced, how often, and at what dosages.*

Were these previous experiences helpful and considered positive? Or not helpful? Please explain.*

Do you have any medical conditions, injuries, or physical limitations? Please list them here in detail.*

What level of physical activity are you comfortable with (hiking, walking up and down stairs, etc)? Please explain.*

Please list any current medications you are taking by name and dosage and what they are for.*

Please list any current supplements/homeopathic/Ayurvedic/Chinese medicine remedies by name that you are taking.*

Are you willing and able to discontinue any medications and supplements that are contraindicated with psilocybin at least 2 weeks before the retreat (more details to follow)?*

YesNo

How sensitive are you to things like caffeine, over the counter pain medication, and cough syrup?

Have you ever fainted?*

YesNo

Do you or anyone in your family have a history of epilepsy or seizures?*

YesNo

Are there any needs you have for this retreat (physical or otherwise) that we need to be aware of?*

Please give a thorough mental health overview, including traumas or issues you are currently working through.*

Have you seen or are you currently seeing a therapist or personal coach?*

YesNo

What spiritual practices do you engage with and how do these practices support you?*

Is there anything else you would like us to know that has not been addressed in this form?*

Do you have any food allergies or dietary needs that we need to know about (especially chocolate since the mushrooms may be served in the form of chocolates)?*

Tulum March 21-26, 2025 Retreat