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Eleusis Application
We're excited to book our initial call with you, but first let's get to know you better.
18
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1
Name
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First Name
Last Name
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2
How would you categorize yourself?
Check all that may apply to you
Interested in Exploring Consciousness
Psychonaut / Experienced with Psychedelics
Practitioners Seeking Employment
Ready to meet Aliens, Machine Elves and Entities
Not Sure Yet
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3
E-mail
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example@example.com
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4
Phone Number
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5
Your Location
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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6
What Timezone do you live in?
*
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GMT-12:00, Baker Island Time (BIT)
GMT-11:00, Niue Time (NUT), Samoa Standard Time (SST)
GMT-10:00, Hawaii-Aleutian Standard Time (HAST), Cook Islands Time (CKT), Tahiti Time (TAHT)
GMT-09:30, Marquesas Islands Time (MART)
GMT-09:00, Alaska Standard Time (AKST), Gambier Islands Time (GIT)
GMT-08:00, Pacific Standard Time (PST), Clipperton Island Time (CIST)
GMT-07:00, Mountain Standard Time (MST)
GMT-06:00, Central Standard Time (CST), Galápagos Time (GALT)
GMT-05:00, Eastern Standard Time (EST), Colombia Time (COT), Cuba Standard Time (CST), Ecuador Time (ECT), Peru Time (PET)
GMT-04:30, Venezuelan Standard Time (VET)
GMT-04:00, Atlantic Standard Time (AST), Amazon Time (AMT), Chile Standard Time (CLT), Paraguay Time (PYT)
GMT-03:30, Newfoundland Standard Time (NST)
GMT-03:00, Argentina Time (ART), Brasília Time (BRT), Falkland Islands Time (FKT), French Guiana Time (GFT), South Georgia Time (GST), Uruguay Time (UYT)
GMT-02:00, Fernando de Noronha Time (FNT), South Sandwich Islands Time (GST)
GMT-01:00, Azores Standard Time (AZOT), Cape Verde Time (CVT)
GMT+00:00, Greenwich Mean Time (GMT), Coordinated Universal Time (UTC), Western European Time (WET)
GMT+01:00, Central European Time (CET), West Africa Time (WAT), British Summer Time (BST)
GMT+02:00, Eastern European Time (EET), Central Africa Time (CAT), Israel Standard Time (IST), South Africa Standard Time (SAST)
GMT+03:00, Moscow Standard Time (MSK), East Africa Time (EAT), Arabia Standard Time (AST)
GMT+03:30, Iran Standard Time (IRST)
GMT+04:00, Gulf Standard Time (GST), Armenia Time (AMT), Azerbaijan Time (AZT), Georgia Standard Time (GET)
GMT+04:30, Afghanistan Time (AFT)
GMT+05:00, Pakistan Standard Time (PKT), Maldives Time (MVT), Yekaterinburg Time (YEKT)
GMT+05:30, Indian Standard Time (IST), Sri Lanka Standard Time (SLST)
GMT+05:45, Nepal Time (NPT)
GMT+06:00, Bangladesh Standard Time (BST), Bhutan Time (BTT), Omsk Time (OMST)
GMT+06:30, Cocos Islands Time (CCT), Myanmar Time (MMT)
GMT+07:00, Indochina Time (ICT), Krasnoyarsk Time (KRAT), Western Indonesia Time (WIB)
GMT+08:00, China Standard Time (CST), Hong Kong Time (HKT), Singapore Time (SGT), Australian Western Standard Time (AWST), Irkutsk Time (IRKT)
GMT+08:45, Australian Central Western Standard Time (ACWST)
GMT+09:00, Japan Standard Time (JST), Korea Standard Time (KST), Yakutsk Time (YAKT)
GMT+09:30, Australian Central Standard Time (ACST)
GMT+10:00, Australian Eastern Standard Time (AEST), Vladivostok Time (VLAT)
GMT+10:30, Lord Howe Standard Time (LHST)
GMT+11:00, Solomon Islands Time (SBT), Magadan Time (MAGT)
GMT+12:00, Fiji Time (FJT), New Zealand Standard Time (NZST), Kamchatka Time (PETT)
GMT+12:45, Chatham Islands Time (CHAST)
GMT+13:00, Tonga Time (TOT), Phoenix Islands Time (PHOT)
GMT+14:00, Line Islands Time (LINT)
Please Select
Please Select
GMT-12:00, Baker Island Time (BIT)
GMT-11:00, Niue Time (NUT), Samoa Standard Time (SST)
GMT-10:00, Hawaii-Aleutian Standard Time (HAST), Cook Islands Time (CKT), Tahiti Time (TAHT)
GMT-09:30, Marquesas Islands Time (MART)
GMT-09:00, Alaska Standard Time (AKST), Gambier Islands Time (GIT)
GMT-08:00, Pacific Standard Time (PST), Clipperton Island Time (CIST)
GMT-07:00, Mountain Standard Time (MST)
GMT-06:00, Central Standard Time (CST), Galápagos Time (GALT)
GMT-05:00, Eastern Standard Time (EST), Colombia Time (COT), Cuba Standard Time (CST), Ecuador Time (ECT), Peru Time (PET)
GMT-04:30, Venezuelan Standard Time (VET)
GMT-04:00, Atlantic Standard Time (AST), Amazon Time (AMT), Chile Standard Time (CLT), Paraguay Time (PYT)
GMT-03:30, Newfoundland Standard Time (NST)
GMT-03:00, Argentina Time (ART), Brasília Time (BRT), Falkland Islands Time (FKT), French Guiana Time (GFT), South Georgia Time (GST), Uruguay Time (UYT)
GMT-02:00, Fernando de Noronha Time (FNT), South Sandwich Islands Time (GST)
GMT-01:00, Azores Standard Time (AZOT), Cape Verde Time (CVT)
GMT+00:00, Greenwich Mean Time (GMT), Coordinated Universal Time (UTC), Western European Time (WET)
GMT+01:00, Central European Time (CET), West Africa Time (WAT), British Summer Time (BST)
GMT+02:00, Eastern European Time (EET), Central Africa Time (CAT), Israel Standard Time (IST), South Africa Standard Time (SAST)
GMT+03:00, Moscow Standard Time (MSK), East Africa Time (EAT), Arabia Standard Time (AST)
GMT+03:30, Iran Standard Time (IRST)
GMT+04:00, Gulf Standard Time (GST), Armenia Time (AMT), Azerbaijan Time (AZT), Georgia Standard Time (GET)
GMT+04:30, Afghanistan Time (AFT)
GMT+05:00, Pakistan Standard Time (PKT), Maldives Time (MVT), Yekaterinburg Time (YEKT)
GMT+05:30, Indian Standard Time (IST), Sri Lanka Standard Time (SLST)
GMT+05:45, Nepal Time (NPT)
GMT+06:00, Bangladesh Standard Time (BST), Bhutan Time (BTT), Omsk Time (OMST)
GMT+06:30, Cocos Islands Time (CCT), Myanmar Time (MMT)
GMT+07:00, Indochina Time (ICT), Krasnoyarsk Time (KRAT), Western Indonesia Time (WIB)
GMT+08:00, China Standard Time (CST), Hong Kong Time (HKT), Singapore Time (SGT), Australian Western Standard Time (AWST), Irkutsk Time (IRKT)
GMT+08:45, Australian Central Western Standard Time (ACWST)
GMT+09:00, Japan Standard Time (JST), Korea Standard Time (KST), Yakutsk Time (YAKT)
GMT+09:30, Australian Central Standard Time (ACST)
GMT+10:00, Australian Eastern Standard Time (AEST), Vladivostok Time (VLAT)
GMT+10:30, Lord Howe Standard Time (LHST)
GMT+11:00, Solomon Islands Time (SBT), Magadan Time (MAGT)
GMT+12:00, Fiji Time (FJT), New Zealand Standard Time (NZST), Kamchatka Time (PETT)
GMT+12:45, Chatham Islands Time (CHAST)
GMT+13:00, Tonga Time (TOT), Phoenix Islands Time (PHOT)
GMT+14:00, Line Islands Time (LINT)
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7
Do you have experience with psychedelics?
*
This field is required.
More than 10 experiences
5-10 experiences
Less than 5 experiences
No experience with psychedelics
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8
When was the last time you had a Psychedelic experience?
Please Select
In the last year
Less than 5 years
5 to ten years
Over ten years
Please Select
Please Select
In the last year
Less than 5 years
5 to ten years
Over ten years
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9
What Psychedelic molecules or compounds have you tried?
*
This field is required.
Please list all hallucinogenic and dissociative compounds that you have tried
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10
How many breakthrough experiences have you had with Psychedelic?
*
This field is required.
More than 10 breakthroughs
5-10 breakthroughs
Less than 5 breakthroughs
1 to 3 breakthroughs
No experience with psychedelics
I'm not sure
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11
Do you have specific intentions about what you hope to get out of this experience?
Choose as many that apply
I have tried many psychedelics, and I’m curious about the ‘breakthrough’ DMTx experience.
I am seeking wisdom from the experience that can improve my life.
I am looking for a deep psychedelic experience in a safer, more medical setting.
I am looking for a comfortable experience at a resort setting more familiar to the level of hospitality I am accustomed.
I am hoping that DMTx will be a transformative experience in the treatment of my mental health concerns
I am looking to get a new perspective on creativity, personal, professional or athletic performance
I am interested in meeting and convening with entities
I am looking for a religious-type experience
I’m a psychonaut, and I want to be one of the first on the planet to experience DMTx
I am interesting in contributing to research
Other
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12
Eleusis is a luxury, all-inclusive wellness immersion at a private oceanfront villa, offering transformative experiences with expert medical care, gourmet meals, and holistic support.
*
This field is required.
I’m comfortable investing in a luxury retreat in the $15,000–$25,000+ range
I’m open to premium experiences in the $10,000–$15,000 range
I’m interested, but my budget is below $10,000
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13
Select programs you'd be interested in:
Eleusis is licensed to utilize all psychedelic compounds, and we are planning to develop programs using other compounds in the near future.
DMTx: The Breakthrough Experience
Unlocking Peak Athletic Mental Performance
Creativity & Music Production
Creativity & Visual Arts
Navigating Career Transitions & Life Purpose
Entwined: Psychedelics for Deeper Couple's Connection
Mental Health – Depression, Anxiety, PTSD, Addiction
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14
Are you willing to provide anonymous biometric data and personal accounts of your medicine experiences?
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15
Do you have a passion for social media?
YES
NO
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16
Which platforms are you active on?
Eleusis is licensed to utilize all psychedelic compounds, and we are planning to develop programs using other compounds in the near future.
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17
How did you hear about DMTx
I’ve been following psychedelics for some time and/or read books about DMT
I’ve read some of the research papers about DMTx
I’ve only heard a little about DMTx
Noonautics mentioned DMTx
Carl Hayden Smith
Andrew Gallimore
Internet Searches
Social Media
Other
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18
Is there anything else you'd like to tell us?
Tell us more about you and why you're interested in this experience
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19
Before you go, Please Follow us
on your favorite social media platform to stay up to date
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