Retreat Intake Form
Please take a few moments to complete this intake form. Your responses help us better understand your background, support your safety, and discern readiness and alignment for this experience. All information shared here is held with care and confidentiality.
Basic Information
Please provide your contact details.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Name
First Name
Last Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Do you currently live in Hawai‘i?
Yes
No
Which retreat or private ceremony are you applying for?
Please Select
Crested Butte, CO - Feb 2026
Ericeira, Portugal - April 2026
Lanikai, HI - June 2026
Lanikai, HI - Sept 2026
Private Retreat
Other
Mental Health History — Personal
Please answer regarding your personal mental health history.
Have you ever received any mental health diagnoses?
Schizophrenia
Schizoaffective disorder
Bipolar I
Bipolar II
PTSD
Depression
Anxiety or Panic Disorder
ADHD or Autism / Neurodivergence
None of the above
Other
If you checked ADHD or Autism / Neurodivergence, is there anything you’d like us to know about how this shows up for you or how we can support you in ceremony?
Are you currently experiencing suicidal thoughts, significant emotional instability, or a period of acute crisis?
Yes
No
Mental Health History — Family
Family mental health background.
Have any parents or siblings been diagnosed with schizophrenia, schizoaffective disorder, bipolar I, bipolar II, or other major psychiatric conditions?
Yes
No
If yes, please share what feels relevant.
Medical History — Physical Health
Please answer about your physical health.
Do you have any chronic medical conditions or anything you believe may be relevant for us to know as your facilitator?
Have you ever experienced seizures (not including childhood febrile seizures)?
Yes
No
Have you ever experienced fainting episodes?
Yes
No
Have you ever experienced heart conditions?
Yes
No
Have you ever experienced traumatic brain injury or concussion?
Yes
No
Have you ever experienced stroke?
Yes
No
Is there anything else you’d like us to know about your physical health?
Medications & Supplements
Please answer about your current medications or supplements.
Are you currently taking any prescription medications?
Yes
No
If yes, please include the medication name, dosage, reason prescribed (if you’re comfortable sharing), and how long you’ve been taking it.
Are you taking any herbal supplements, sleep supports, or over-the-counter remedies regularly?
Substance Use History
Your relationship to substances.
Do you currently use any substances including alcohol, cannabis, or recreational or therapeutic substances? If so, please share whatever feels relevant about frequency and context.
Have you ever moved through a period of dependency, misuse, or difficulty moderating your use of any substance?
Psychedelic Experience
Your experience with psychedelic medicines.
Have you ever worked with psychedelic medicines before?
Yes
No
If yes, which medicines have you worked with?
In what contexts have you worked with these medicines?
Ceremonial
Therapeutic
Recreational
Solo
Guided
Other
Looking back on your past psychedelic experiences, are there any insights, lessons, or takeaways that have stayed with you?
Have you ever had challenging or overwhelming moments during a psychedelic experience?
Yes
No
If you’re willing to share, how did this challenge show up for you? What helped you feel supported during that experience?
Emotional Landscape & Readiness
Your current emotional state and intentions.
What draws you to this experience at this particular moment in your life?
Are there intentions, themes, or areas of exploration you feel called toward?
Do you have any trauma history you feel might be relevant to your experience in ceremony? Brief answers are welcome; no details are required.
Is there anything that tends to dysregulate your nervous system that you’d like us to be aware of?
Support Systems & Aftercare
Your support system and aftercare planning.
Who or what makes up your support system right now?
After the experience, will you have space for rest, reflection, and integration?
Yes
No
Not sure
Do you anticipate needing additional support following the ceremony?
Yes
No
Not sure
Accommodations & Logistics
Help us support your unique needs.
Do you have any dietary needs or allergies?
Do you have any physical, sensory, emotional, or spiritual accommodations you would like us to know about so we can support you more fully?
How did you hear about Kalama Retreats or this offering?
Agreement & Consent
Please review and affirm the following.
Do you affirm that the information you are providing is truthful and complete to the best of your knowledge?
Yes
No
Do you understand that completing this form does not guarantee participation and that readiness and alignment will be assessed based on your intake and any follow-up conversation?
Yes
No
Please sign your name as digital consent.
Submit Intake Form
Submit Intake Form
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