DAY TRIPS (CO): Intake Form

DAY TRIP

A private 24-hour ceremonial experience
We work with a variety of plant medicines at Eden. For DAY TRIPS, we work with Anima Mundi which is a blend that you will only find at Eden. It is both spiritually connecting (entheogen) and heart-opening (empathogen).

*Additional details about Anima Mundi and what your experience will look like are shared on your Discovery Call with Dr. Stefanie.
- Day Trips include:
- 1 Zoom Preparation Session with Dr. Stefanie
- 1 Private Medicine Ceremony
- 1 Overnight Accommodation
- 2 Zoom Post-Ceremony Integration Sessions with Dr. Stefanie
- 1 "Before You Trip" Kit
- Total Investment: $9,400
There is a lot of attention being given to psychedelics right now. Eden continues to be a leader in the space and our experiences fill up quickly. The sooner you submit your Intake Paperwork, the better!

We look forward to welcoming you!
Group Day Trip Package ($4444)Couple's Day Trip Package ($6955)Private/Semi-Private Day Trip Package ($9399)
Please list 4-5 preferred dates, including both weekdays and weekend options if possible.*
Let us know 4-5 preferred dates:*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Current or most recent profession*
Linkedin Profile or other Professional/Career Page. If no career page, please include a link to social media page*
Education*
Age*
Date of Birth*

MonthDayYear
Date
When was your last physical exam?*
Medical Conditions:*
Current Medications & Supplements:*
If you take any form of hormones (ie: Hormone Replacement Therapy, Testosterone, Steroids, etc), please list what you take:*
Psychological Conditions:*
SeizureConcussionPsychosis or psychotic breakMania or manic episodePanic attackPanic disorderSuicidal ideationSuicide attemptHistory of violence or violent outburstFamily history of psychosis or psychotic breakFamily history of mania or manic episodeHave you ever been diagnosed as bipolar or manic-depressive?None of these apply to me
Emergency Contact:*
NoYes
NoYes
If yes to the question above about authority, please explain:*
Please tell us about your experience with plant medicine. If you have no experience, simply write "No experience" in the box below.*
Your intention with this experience*
YesNo
How did you learn about The Sacred House of Eden?*
If you have been referred to us, please tell us (by name) who referred you to Eden:
Anything else you feel is important for us to know:
If you have been with us before, when is the last time you joined us for Retreat?
YesNo
If yes, please briefly share your service background:*
Please upload a copy of your driver's license or other form of ID. We need this for proof of age over 25 years old (JPG or JPEG only)*

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By signing this form, I confirm to The Sacred House of Eden that I am over the age of 25 years, and that I am physically capable of participating in the experiences provided by The Sacred House of Eden. I understand and agree that it is my sole responsibility to consult a physician or other qualified health care provider with regard to my ability to participate in this experience. I further understand that my participation in the experience and all activities during the experience are at my own risk and responsibility.*
I understand that The Sacred House of Eden is not a licensed facilitator, but rather a non-profit Visionary Temple in the state of Colorado that provides bona fide harm reduction and support services used concurrently with the sharing of psychedelic natural plant medicines. I understand that Eden is a safe container that provides beneficial community-based use and healing, coaching, and spiritual guidance*
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Deposit for DAY TRIP
To secure your spot for a DAY TRIP, pay your deposit now. We will reach out to you to set up a Consult Call with Dr. Stefanie. If for any reason we determine this is not a good fit, we will immediately refund your deposit.

$350.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00
Payment Methods

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