Kalama Retreats Intake Form

Kalama Retreats Intake Form

Share a little about your background, intentions, and what is calling you to this experience.
Welcome

Thank you for taking the time to complete this intake form. These questions help me understand what is bringing you to this retreat and how best to support your journey. Some are reflective, while others help ensure that the retreat environment is safe, thoughtful, and supportive for everyone involved. Please answer as openly as you feel comfortable. Everything shared here is held in confidence and helps me prepare the container for our time together.
Your Journey
What drew you to this retreat at this moment in your life?
What are you hoping to explore, heal, or better understand during this experience?
Are there any life transitions, challenges, or meaningful changes unfolding in your life during this season? (Examples might include career shifts, relationship changes, grief or loss, health challenges, family dynamics, or spiritual exploration.)
What would a meaningful experience at this retreat look like for you?
Do you have any fears, hesitations, or uncertainties about participating in this retreat? (It’s completely natural to feel some nervousness when approaching experiences like this. Often that feeling is simply a signal that something meaningful is unfolding.)
These might relate to the medicine experience, group dynamics, emotional vulnerability, travel, or anything else.
Previous Experience
Have you worked with psychedelic medicines before?
Which medicines have you worked with?

Other
In what contexts have you explored these medicines? (Examples might include recreational settings, concerts or festivals, time in nature or camping, solo exploration, guided or ceremonial spaces, therapeutic settings, or microdosing.)
Was there anything particularly meaningful about those experiences?
Have you ever had a challenging or intense psychedelic experience? If so, how did you move through it and what did you learn from it?
If you haven't had psychedelic experiences before, feel free to share how you typically navigate emotionally challenging situations.
Support & Integration
Do you currently work with a therapist, coach, or integration guide?
Do you have supportive people in your life who know you are attending this retreat?
Boundaries & Comfort
Are you comfortable with supportive touch if requested during ceremony?
Are there any particular situations, environments, or experiences that tend to make you feel unsafe or overwhelmed?
Examples might include darkness, loud sounds, physical touch, crowded spaces, feeling physically confined, or emotional confrontation. This helps us support you more skillfully if needed.
Do you have any sensory sensitivities we should be aware of?
Examples might include sensitivity to strong scents, smoke or incense, loud sounds, music volume, lighting, or physical proximity to others.
Is there anything that helps you feel safe or supported during vulnerable experiences?
Examples might include music, silence, being outdoors, reassurance from a facilitator, grounding through breath, space to move your body, or simply being left alone for a time.
Mental & Emotional Health
Have you been diagnosed with any of the following?
Have you or any of your direct relatives (parents or siblings) ever been diagnosed with schizophrenia or schizoaffective disorder?
Are you currently taking psychiatric medications?
If yes, please list medications and dosage.
Physical Health
Do you currently have any medical conditions we should know about?
Do you have any cardiovascular conditions?
Allergies, dietary restrictions or preferences?
We're here to serve you! Special requests for your dietary preferences are welcomed!
List any medications or supplements you take regularly, along with their dosages.
Lifestyle & Preparation
What practices support your wellbeing?

Other
Optional massage or bodywork treatments will be available during our integration day as an optional add-on ($150-200 per treatment). Because I’ll be bringing practitioners in specifically for our group, it would be helpful to have a sense ahead of time of how many people may want to receive a treatment. Would you like me to reserve a spot for you?
*If you choose to decide later, please keep in mind that 1–2 weeks’ notice may be needed to guarantee availability.
Emergency Contact
Emergency contact name
Relationship
Emergency contact phone number
Final Reflections
Is there anything else you would like me to know before the retreat?
Do you have any questions or concerns you'd like to discuss beforehand?
Should be Empty:

Kalama Retreats Intake Form

Welcome

Your Journey

Previous Experience

Support & Integration

Boundaries & Comfort

Mental & Emotional Health

Physical Health

Lifestyle & Preparation

Emergency Contact

Final Reflections