Returning To Source 2027 - Retreat Application & Intake

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What is your full name? (as it appears on your passport)* This field is required.
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What is your preferred first name?* This field is required.How would you like us to refer to you?
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What is your mobile number? (Whatsapp and/or Signal)* This field is required.
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Phone Number
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What is your email?* This field is required.
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Please confirm email * This field is required.Type your email again here
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What is your relationship status?* This field is required.single, married with children, married, widowed, separated or divorced, other.
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What is your date of birth?* This field is required.
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What is your height?* This field is required. In centimeters.
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What is your weight? * This field is required.In kilograms.
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What is your nationality and passport number?* This field is required.
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What is your city and country of residence?* This field is required.
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How did you find out about Returning To Source retreat & pilgrimage? If you were recommended by someone, can you please include their name.* This field is required.
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Have you travelled internationally before? If so, where? Have you travelled to Cusco or the Sacred Valley before?* This field is required.
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Please provide the details of an emergency contact person.* This field is required.Please include full name, email, mobile number and your relationship to this person.
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Are you currently employed? If so, what is your work/profession?* This field is required.
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Please click if you have any of the following, or if you have ever been diagnosed in the past with any of the following:* This field is required.
Diabetes
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Infectious or contagious disease
Cancer
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Chest pain or angina
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Other
None of the above
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If you clicked on any of the above, please explain more about the condition(s) including whether there has been any resolution or whether these diagnoses/issues are still persistent in your life. * This field is required.
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Do you have a history of, or do you currently have, any medical conditions (i.e: not psychiatric diagnoses) that were not listed in the above question? If yes, please explain. * This field is required.
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Are you currently taking any prescription drugs? Please include dosage, frequency, and purpose of use.* This field is required.
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Are you currently taking any non-prescription, over-the-counter medications, supplements, or herbal products? Please include dosage, frequency, and purpose for use.* This field is required.
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Has there been a history of psychosis, schizophrenia, bipolar, mood disorders, or other severe mental illness in your family? * This field is required.
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Have you ever seen a psychologist or psychiatrist for any mental health issue or crisis, and been diagnosed with any of the following conditions listed below?* This field is required.
Anxiety
Depression
Post-Traumatic Stress Disorder (PTSD)
Bipolar Disorder (Type 1 or 2)
Attention Deficit Hyperactivity Disorder (ADHD)
Obsessive Compulsive Disorder (OCD)
Panic Attacks
Self-Harming
Attempted Suicide
Schizophrenia or Psychotic Episode
Personality Disorder
Eating Disorder
Other
None of the above
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If you clicked on any of the above conditions, please explain more about your past and/or current situation with them. * This field is required.
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Have you ever been hospitalized for medical or psychiatric reasons in your life? If so, please elaborate on the context of this hospitalization(s). * This field is required.
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Have you ever taken, or are you currently taking, antidepressants, antipsychotics, or benzodiazapines? Please share the name of the medication, dosage, frequency, and what you're taking this for. * This field is required.
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Do you currently struggle with any addictions, or do you have a past history of addictions? Please describe thoroughly below.* This field is required.
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Do you use recreational substances, such as cannabis, cocaine, methamphetamines, etc.? If so, please describe your use.* This field is required.
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Do you currently use alcohol? If so, how often do you use alcohol?* This field is required.
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Do you have any experience with teacher plants or psychedelic substances in any capacity? Please describe previous psychedelic use, including context(s).* This field is required.
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Have you experienced overwhelming side effects or have you had very difficult experiences that you have not been able to integrate from working with psychedelics, plant medicines, or expanded states of consciousness?* This field is required.This includes breathwork, meditation, spiritual practices, and any other explorations of altered states.
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Are you pregnant?* This field is required.
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Do you currently have a therapist, mentor, and/or support group? * This field is required.Please describe your engagement.
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List any food or drug intolerances/allergies here.* This field is required.Please include the severity and any necessary notes.
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Do you have a specific food preference? Please share whether or not you eat meat, if you're vegan or vegetarian, etc. * This field is required.
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Do you have any strong sensitivities or intolerances to scents/smells? Please describe.* This field is required.Eg: tobacco, sage, palo santo, perfumes, incense, etc.
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Which lodging & pricing option are you applying for?* This field is required.
Please Select
Please Select
Early Bird - Two-person shared room $2,600 USD (Available before May 1, 2026)
Early Bird - Private Room $3,000 USD (Available before May 1, 2026)
General - Two-person shared room $2,850 USD (After May 1, 2026)
General - Private Room $3,200 USD (After May 1, 2026)
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Are there any major sources of stress in your life at the moment, or any symptoms that you are experiencing, which are impacting your health and well-being?* This field is required.
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Are you experiencing any forms of psychospiritual crisis (i.e spiritual emergency)? If yes, please provide some brief detail of what you're experiencing.* This field is required.
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Do you have a self-care, embodiment or spiritual practice that you engage in? If yes, what is it and how many times a week?* This field is required.
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What makes you feel connected and resourced in your life? Please list at least 3 people, practices, or things that support you to feel resourced in your life.* This field is required.
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Do you identify with any religious or spiritual beliefs? Please describe.* This field is required.
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What are your motivations/intentions for wanting to participate in this ceremonial retreat & pilgrimage?* This field is required.
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Are there any aspects of this retreat & pilgrimage that you are particularly drawn to?* This field is required.
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Do you have any expectations, fears and/or concerns for engaging in this retreat & pilgrimage?* This field is required.
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What are you most longing for in your life right now?* This field is required.
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During this retreat & pilgrimage, there will be one mystery sacred medicine ceremony offered in which the contents of the brew will not be revealed to the participants. Is this something that you feel comfortable with? Please know that you will be welcome to skip this experience if you do not wish to participate.* This field is required.
YESNO
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Would you like to be added to our mailing lists to receive updates on our offerings, workshops and upcoming events?* This field is required.
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Please upload a photo of yourself (Max 10.6 MB). We will only use this photo to identify you throughout the application process.* This field is required.
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As part of the preparation for the retreat, we ask that you arrive to Cusco, Peru one day before the retreat starts (January 7, 2027). Do you agree to this?* This field is required.
YESNO
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Declaration Signature: By signing this form, I confirm that everything I have shared in this intake form is honest and true, and that I did not withhold any important information about my medical, psychological/emotional, and physical health and well-being. If anything changes between the time I complete this form and the date of the retreat, I commit to informing Alyona Kobevka, Alexandre Jodun and Ramon Aleman of these changes as soon as I become aware of them.* This field is required.
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As a reminder, please click the "SUBMIT" button below in order to officially complete this application. If you do not click submit, we will not receive your application and you may lose your responses. After you click submit, please go ahead and book in your interview (the link is at the bottom of the webpage).* This field is required.
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