Gather Well Psychedelics: Retreat Registration Form

Retreat Registration Form

Greetings! This form is to secure your spot for a Gather Well Ceremonial Retreat. Please answer each question below with as much detail as possible. Once you have filled out this registration form, you will be sent a more thorough intake form that will be reviewed by a member of our Gather Well Team.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Our website/social mediaColleagueFriendMy Guide/ Therapist/ HealerOther
Name of friend, colleague (if comfortable sharing):
What is your intention in joining this retreat? How do you see it supporting your life or work?
Dates for The Retreat

Gather Well will be hosting 2 ceremonies in April.

Group 1: Saturday, April 25th – Monday, April 27th
- Saturday: Arrival at 11am, light snack provided, preparatory activities until 4pm, Ceremony begins at 5pm
- Sunday: Integration activities until 6pm, Dinner provided (participants may leave after dinner if needed)
- Monday: Breakfast provided, departure by 10am
Group 2: Monday, April 27th – Wednesday, April 29th
- Monday: Arrival at 12pm, light snack provided,preparatory activities until 5pm, ceremony begins at 6pm
- Tuesday: Integration activities until 6pm, dinner provided (participants may leave after dinner if needed)
- Wednesday: Breakfast provided, departure by 10am
Group 1: Saturday, April 25th – Monday, April 27thGroup 2: Monday, April 27th- Wednesday, April 29thI could join either one (this helps us plan and manage waitlists)
The full cost to participate in the retreat is $1,800 per person, per ceremony. This includes two individual preparation sessions, one group preparation session, two nights and three days of lodging, a full group ceremony, all meals on site, and two individual integration sessions.

If you feel inspired and have the capacity to contribute more, you are welcome to give up to $2,200. Any amount above the base cost will directly support someone who might not otherwise be able to attend, helping us make this work more accessible to everyone.
I am able to pay the full cost of the retreat.I could pay more than the full cost of the retreat to support a participant of lesser means in joining the retreat.I am unable to pay the full cost of the retreat and would need to speak to a member of the Gather Well team about what might be available.
Experience with Expanded State/Psychedelics

It is important that we get a clear understanding of your prior experience for your own well being and that of other participants.
Please describe your experience with engaging expanded and/or non-ordinary states induced by psychedelics or other substances for the purposes of healing. In your description please indicate the kinds of modalities and the contexts or reasons for which they were engaged, an approximate number of times engaged, and a very brief description of how it was beneficial or not beneficial to you. If describing work done outside of a legal context, please omit specifics (such as any identifying information of other people, locations, etc) Please only write here work done that you are comfortable disclosing in writing. Further discussion can be had in the interview phase to fill in any information omitted in this section. Please indicate below if this is the case.
Have you done any work with psychedelics in an intentionally held group setting (not recreational/party setting), if not already indicated above?
Have you experienced any adverse experiences with psychedelics? Please briefly describe, or indicate you’d like to discuss in an interview.
As a next step in the process, we will ask you to complete a comprehensive intake and health screening. At this stage, are there any health considerations or concerns you’re aware of that might affect your ability to safely participate in work with psilocybin mushrooms? Briefly describe.
Do you have any logistical questions you would like answered through a follow up email or brief phone call?

My Products

Retreat Deposit

This deposit is non refundable and secures your place on the retreat. In the event that, after reviewing your full intake, we determine that participation would not be in your best interest for safety reasons, the deposit will be fully refunded.

$300.00 Quantity

Total

$0.00

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Retreat Registration Form

Experience with Expanded State/Psychedelics

It is important that we get a clear understanding of your prior experience for your own well being and that of other participants.