Groundwork 2025: an exploration for healing arts and collective practice in these times

Groundwork Program 2025: Application Form

All personal information collected is secured through Homecoming by Medstak, a HIPAA-compliant hosting platform that provides rigorous, industry-standard security requirements. Your personal identity information will be viewed only by Gather Well Staff, Program Staff, and Health Screening Contractors.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact Name and Phone Number:
How did you find out about the program? Please check one box:

Our website/social mediaColleagueFriendMy Healer/Guide/TherapistOther
References

Compatibility between the program and participants is really important to us. Though we know people often choose references that will provide favorable information, please consider listing references that will provide balanced information about you. This serves our ability to support you through the program. Please provide names, email addresses and phone numbers of two educational, professional, clinical or character references.
Reference #1: Name, Phone, Email & Context of Relationship
Reference #2: Name, Phone, Email & Context of Relationship
Location

Some themes of the program are about place connectedness and so we hope to group cohorts together based on location as much as possible. A few components of the program we hope to have occur in person with your cohort peers. Additionally, we will try to group cohorts by timezone as much as possible.
What is, or will be, your location for the duration of the program?
What is, or will be, your location for the duration of the program? [City, State, Timezone]
Any comments about your location for the program duration.
NOTE as you write in answers below: Please do not write any specifics (people's names, dates, or locations) about experience with entheogens or psychedelics that were conducted in an illegal context.
Intentions and Goals
What brought you to apply for our program? What do you hope to gain personally?
What is your intention after completion of this program? How do you see it supporting your life or work?
This program emphasizes personal growth, vulnerability, authenticity, and group work. What excites you about this kind of deep personal and collective work? What, if anything, feels challenging or intimidating about it?
At this point in time do you have interest in pursuing Gather Well’s Psychedelic Apprenticeship Program?
Identity, Positionality, and Social Context

Please fill in this section as transparently as you feel comfortable for the purpose of us providing you with a more attuned approach to your experience with us, and to support us in our commitment to equity and creating a diverse community of program participants. All information is kept strictly confidential amongst relevant organizational and program staff.
Current Age (answer required for correlation with medical questions)
Preferred Gender Pronouns
Creating an explicit culture around sharing pronouns is one way to support people's right to determine how they want to be addressed, and affirms the dignity of trans and gender expansive people. Should you choose not to share your pronouns, we will respect this decision and expect that you respect how others wish to be addressed.
Identity: Please describe how you identify. Include all aspects you feel comfortable sharing. Consider your race, class, gender, sexual orientation, and other aspects of your identity. Below are some options to help you provide a nuanced description. Please add any further aspects or context that feel important to you
.
Gender Identity:
- Cisgender man
- Cisgender woman
- Gender-nonconforming or Genderqueer
- Non-binary
- Questioning or Unsure
- Transgender man
- Transgender woman
- Two Spirit
Racial Identity and Identification
- African/African American/Black
- Arab/Arab American/Middle Eastern
- Asian/Asian American
- Indigenous - please describe
- Latinx
- Mixed/Multiracial
- Pacific Islander
- South Asian
- White/European American
Sexual Orientation
- Asexual
- Bisexual
- Celibate
- Demisexual
- Gay
- Heterosexual/Straight
- Lesbian
- Pansexual
- Queer
- Questioning or Unsure
Neurodivergence
- ADHD
- Autism Spectrum Identified
- Tourette's Syndrome
- Sensory Processing (SPD)
- Dual Diagnosis - please describe
Briefly describe the relationship between your racial identity (how you identify) and your racial identification (how others might understand and categorize you). This may be the same for you or very different.
Has your position as a dominant or non-dominant racial identity ever changed based on relocating where you live? Please describe.
If you identify as neuro-divergent, how do you anticipate this may influence your time with us? How do you think we can best accommodate your needs?
If you identify as differently able-bodied, how do you anticipate this may influence your time with us? How do you think we can best accommodate your needs?
Do you have any health challenges or personal needs that could require special care in order to support your participation?
[A more detailed series of questions on your health will be asked further down in the document]
Have you ever been an immigrant?
Do you currently have citizenship in the country in which you reside? (answer required for legal consideration in engaging in the residential retreat activities)
Positionality and Social Context
How do your identities (e.g., race, gender, class, sexual orientation) influence your lived experiences and interactions with others, and how have these identities impacted or been impacted by others?
What work, if any, have you done to unpack your lived experiences related to your identities, and have you engaged in any group processes or learning around these areas?
If you hold a privileged social position, can you share an example of how you’ve explored the impact of privilege or power in your personal life or work?
How have you noticed the concept of “othering” occurring in groups, and how have you experienced being othered or contributed to othering?
What are your thoughts, knowledge, and feelings about cultural appropriation in healing spaces?
In relation to your culture (broadly defined as race, class, sexual orientation, ethnicity, gender identity, religion/spirituality, disability, language, country of origin, immigration status, etc.), positionality, or social context, is there anything else about your identities that are important to you that will be helpful for our program and admissions teams to know about?
Current Experience and Interests
Current offering/work/area of dedication

CoachingSpiritual counseling/ChaplainRitualist/Rites of passage or Vision quest guidePsychedelic guide/ Integration coach/ Ceremonialist/ Psychedelic assisted therapistCommunity organizer/ ActivistTransformative/ Restorative justice facilitator, Rupture and repair mediationDoula/Midwife, Birth or Death guide, Hospice/End of lifeBodyworker/ Touch-based healing approachesPsychotherapy/Social worker/Licensed counselorMedical or Psychiatric professionalAlternative Healing and WellnessOther
We are interested in understanding how you spend your time, energy and efforts towards community, social change and collective healing. (This can range from, thinking deeply about, educating yourself on, being in dialogue with others, being involved in movements and organization, etc. For example you may be involved in environmental sustainability movements, social change, social justice, indigenous rights, mental health reform and so on). Please list out specific areas of interest and involvement and be specific about what involvement means and looks like to you.
Can you provide a specific example of how your personal development journey has led to a positive impact for others or a community you are a part of? And, how have the communities you are a part of sparked or shaped your personal work?
Please describe any ritual or spiritual practices (aside from any use of psychedelics) you maintain and engage with on a regular basis. These are practices you engage to help you feel more connected to yourself and relationship with your growth process, with your care for yourself and others around you (human and non-human), and/or to a greater context of existence. These can be non-dogmatic or un-related to a religious practice. Please explain your practices and how often you engage them.
Experience with Expanded State/Psychedelics

Since some components of the program involve expanded states of consciousness experiences it is important that we get a clear understanding of your prior experience for your own well being and that of other participants.
Please describe your experience with engaging expanded and/or non-ordinary states induced by psychedelics or other substances for the purposes of healing. In your description please indicate the kinds of modalities and the contexts or reasons for which they were engaged, an approximate number of times engaged, and a very brief description of how it was beneficial or not beneficial to you. If describing work done outside of a legal context, please omit specifics (such as any identifying information of other people, locations, etc) Please only write here work done that you are comfortable disclosing in writing. Further discussion can be had in the interview phase of the admission process to fill in any information omitted in this section. Please indicate below if this is the case.
Please click "yes" if there is additional information you would like to discuss related to this question during the zoom interview.

Yes
Have you done any work with psychedelics in an intentionally held group setting (not recreational/party setting), if not already indicated above?
Have you experienced any adverse experiences with psychedelics? Please briefly describe, or indicate you’d like to discuss in an interview.
Interpersonal Dynamics
Offer an example of a situation or time when your nervous system was activated. What signals do you notice when you are dysregulated or activated? How do you respond to this dysregulation or activation within yourself?
What tends to happen for you when another person is activated in a group setting?What tools or approaches do you use to care for yourself and others?
Briefly describe a time when you experienced dissonance or rupture in a group setting. How did you respond, and what did you learn from the experience?
What does repair look like to you after a rupture in a relationship or group dynamic, and how do you navigate the idea that resolution may not happen immediately (or at all)?
What is your process for following through on personal growth insights or feedback from others, especially when that growth impacts the people around you?
How do you navigate complexity, vulnerability, and the unknown in relational dynamics? Please describe a specific time when you made space for, or welcomed, complexity, vulnerability or ambiguity in a situation. What was your internal experience of this and what did that look like externally?
Mental Health and Physical Health History Part 1:

Since some components of our retreats involve expanded states of consciousness experiences involving psychedelics (psilocybin containing mushrooms) it is important that we get a clear sense of your mental health and physical health for your well being and safety. Part 1 will provide an initial opportunity to get to know you in these aspects. A part 2 screening will be provided as a next step in the application process and ask more detailed current and historical mental health and physical health questions to support you in having a safe and beneficial experience. Please respond to the rest of the application thoroughly and honestly.
Mental Health History Part 1:
In general, how satisfied are you with your life?

Very satisfiedMostly satisfiedSomewhat disappointedMostly disappointed

If you have the symptoms below, please check the box that best describes their severity. If you don't have symptoms, leave blank. 1=mild/sometimes 2=moderate/often 3=severe/constant

	1	2	3
Anxiety
Hopeless outlook
Mood Swings
Depression
Lonely
Dislike criticism
Quick to anger
Easily stressed
Nervousness

Have you served in the military?

YesNo
If yes, when and where did you serve, and in what capacity?
Do you have any current or past psychological or psychiatric conditions that have been diagnosed? If yes, please give the dates and describe the circumstances. Do you agree with your diagnosis, and/or what is your relationship to your diagnosis?
Have you ever been hospitalized for a psychiatric condition? If yes, please give the dates and describe the circumstances.
Do you currently see a psychiatrist, psychologist or counselor? How often? How long have you been seeing them?
If yes to the above question, please briefly, disclose within your comfort, what are the themes or personal processes for which you have been seeing them.
Have you ever engaged in ongoing therapy (weekly for a minimum of 3 months)? If yes, how long? Was it helpful? If yes, briefly describe how so. If not, briefly describe why not.
Medical History Part 1
Considering your age, how would you describe your overall health?

ExcellentGoodFairPoor
How would you describe your energy levels?

Low/depletedHigh/excessAppropriate/normalVariable/inconsistent
Date of your last physical
Do you have a doctor with whom you can discuss your engagement with expanded states of consciousness approaches that may involve psychotropic substances in order to get medical clearance from them, should it be necessary?

Do you have any of the following medical issues: [Additional questions on specific medical conditions will be asked in Part 2]

	Yes	No
Hypertension
Renal failure or compromised kidney function
Seizure disorders
Cardiac abnormalities or pathologies

Do you have any other current medical conditions? If so, are you currently in the care of a healthcare professional? Please describe the conditions and current treatment.

Psilocybin mushrooms are contraindicated to pregnancy.

	Yes	No
Are you pregnant?
Are you currently trying to conceive?

Support

This program and experiential components with expanded states of consciousness may lead to profound shifts in your life and it is ideal to have a framework of resources available to support you before, during and after impactful experiences. Having support to integrate the experience can help you to get the most benefit from it.
What friend, loved one, counselor or other trusted person(s) do you speak with about your interest or engagement with expanded states of consciousness? What are their dispositions towards you in pursuing this experience? Do you feel you can ask them for support beyond the support given by Gather Well and its staff?
Is there anyone in your immediate family who is not in support of/ or would not be in support of you pursuing this program and the experiential components with expanded states of consciousness? If yes, please explain how you navigate this dynamic.
Are there any circumstances you currently have or foresee having that could prevent you from showing up for and/or completing Groundwork, i.e. major life transitions, major caretaking roles, etc?
Do you have any questions for us?
By signing this form I attest to the accuracy of the above information. I realize that failure to provide accurate information may compromise my experience or safety, and I have answered this questionnaire truthfully to the best of my ability.

Clear

My Products

Application Fee

$65.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Groundwork Program 2025: Application Form

References

Location

Intentions and Goals

Identity, Positionality, and Social Context

Gender Identity:

Racial Identity and Identification

Sexual Orientation

Neurodivergence

Positionality and Social Context

Current Experience and Interests

Experience with Expanded State/Psychedelics

Interpersonal Dynamics

Mental Health and Physical Health History Part 1:

Mental Health History Part 1:

Medical History Part 1

Support