hOMe Retreat Intake Questionnaire
Please fill out the form below to book your spot for the retreat.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date Of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance Provider (Optional)
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Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship To You?
*
List all medical conditions (Heart, seizures, diabetes, high blood pressure, etc).
*
List all allergies (Food, environment, medications).
*
List all current medications (Prescriptions, OTC, Supplements).
*
Are you currently pregnant or breastfeeding?
*
Yes
No
N/A
Have you ever had a seizure?
*
Yes
No
Do you have any dietary restrictions?
*
Yes
No
If yes, please specify
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Have you ever been diagnosed with: Depression, Anxiety, Bipolar Disorder, Schizophrenia, PTSD, Other
*
Yes
No
Are you currently in therapy or counseling?
*
Yes
No
If yes, please list your therapist’s name/contact (optional).
Do you need support in finding a qualified therapist?
*
Yes
No
Do you have a history of suicidal thoughts or self-harm?
*
Yes
No
Do you have a history of substance use or addiction recovery?
*
Yes
No
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Have you ever participated in a plant medicine ceremony before?
*
Yes
No
If yes, what medicine(s) and when?
What was your experience like?
Do you have any concerns about participating in this retreat?
*
Yes
No
If yes, please list your concerns below.
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What is your personal intention for this retreat?
*
What do you hope to explore, heal, or release?
*
Do you have a support system (friends, family, therapist) for integration after the retreat?
*
Yes
No
Would you like to be paired with an integration coach for follow-up?
*
Yes
No
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Acknowledgment
I commit to confidentiality and respect for all participants.
*
I commit
I agree to sign a Personal Code of Conduct if selected.
*
I agree
I agree to sign a Confidentiality Agreement if selected.
*
I agree
I will abstain from alcohol, recreational drugs, and sexual activity during the retreat.
*
I will abstain
I am committed to following the guidance of the retreat team.
*
I am committed
I understand that my safety and the group’s safety are the highest priorities.
*
I understand
I consent to receive supportive touch during ceremony if needed (e.g., hand on shoulder).
*
Yes
No
I consent to be included in retreat photos/videos (non-ceremony only).
*
Yes
No
I understand that participation in plant medicine carries risks, and I take full responsibility for my health and safety.
*
I understand
I release the retreat facilitators, hosts, and team from liability in case of unexpected outcomes.
*
I release the retreat facilitators, hosts, and team
I acknowledge that participation is voluntary and at the discretion of the retreat team.
*
I acknowledge
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: