🌺 Retreat Intake Form
This intake form is an essential part of the preparation process. It allows us to understand your physical, emotional, and spiritual landscape so that we may hold you safely, consciously, and with deep respect. Please answer with honesty and reflection. All information is confidential and used only for your care and support.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
INTENTION & CALLING
What is your primary intention or prayer for this experience?
What outcomes do you hope to move toward in body, mind, heart, and spirit?
What do you most love about yourself and what do you long to love more fully?
What are you ready to release or forgive within yourself and/or others?
What qualities, strengths, or gifts are you ready to celebrate and embody?
How would you describe your relationship with devotion, surrender, or the sacred?
SPIRITUAL BACKGROUND
Do you have any current spiritual or contemplative practices (meditation, yoga, breathwork, prayer, chanting, journaling, nature immersion)?
Have you participated in ceremonial or transformational work before? If yes, please describe the experience and any insights or challenges that followed.
How do you anchor yourself after deep experiences? What practices and support help you integrate?
Do you have a trusted friend, partner, therapist or a coach who can hold space for you post-retreat?
Your Emergency Contact (name and phone number):
SACRAMENT & MEDICAL HISTORY
Please list any plant medicines or psychedelics you have experienced within the past 10 years
Please share about any significant or challenging experiences that may still feel unresolved
Are you currently taking any medications, supplements, or herbal regiments? Please include dosage and reason (e.g., Losartan 50mg daily, Saw Palemetto for hormonal balancing).
Have you taken any antidepressants such as MAOIs (monoamine oxidase inhibitors) or SSRIs within the last 60 days? If yes, please include dosage and how long have you been taking this prescribed medication?
Have you experienced any of the following (check all that apply):
Seizures
Fainting
Cardiovascular Issues
Asthma and pulmonary issues
Bipolar Disorder
Schizophrenia or psychosis
PTSD or complex trauma
Recent hospitalization & surgeries
Other
BODY & SOMATIC AWARENESS
How does your body respond to stress or strong emotional experiences (e.g., shaking, tears, freezing, expansion, clarity, numbness)?
Do you have any injuries, chronic pain, or limitations we should know about?
How do you nurture your body through food, rest, and movement?
SAFETY & INTEGRITY
Have you experienced significant abuse/trauma (physical, emotional, or sexual)?
If yes, have you received therapeutic or somatic support for it?
Are you comfortable being in a group setting that may include emotional expression and deep process?
Do you understand that this retreat is a sacred, non-recreational space centered in safety, devotion, and reverence?
Yes, I understand and agree
Is there anything else you would like us to know about your health, life circumstances, or soul journey that will help us support you?
CONSENT & AGREEMENT
By signing below, I affirm that all information provided is accurate and complete to the best of my knowledge. I understand that this is not a substitute for medical or psychiatric treatment and that I am responsible for my physical, emotional, and spiritual well-being throughout this process.
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