Retreat Registration

Mexico Psilocybin Retreat

Application
This application helps us understand who you are, where you're at, and whether this retreat is the right fit for you right now. There are no wrong answers — only honest ones. All information is kept strictly confidential.
Full Name
First NameLast Name
Address
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date

Experience and Background
No, this would be my first timeYes, once or twice — recreationallyYes, in a ceremonial or therapeutic contextYes, multiple times in various settings
YesNoNot currently, but I have in the past

Health and Safety
Personal or family history of psychosis or schizophreniaCurrently taking SSRIs, MAOIs, or lithiumDiagnosed bipolar I disorderSignificant cardiovascular conditionCurrently pregnant or breastfeedingNone of the above apply to me
Please list any medications, supplements, or health conditions you'd like us to know about:
Do you have any dietary restrictions or food allergies?

Logistics
How did you hear about this retreat?
Is there anything else you'd like us to know before we connect?
By submitting this application, you confirm that you are 21 years of age or older and that the information provided is truthful to the best of your knowledge. Submission does not guarantee a spot —I will follow up within 3–5 business days.
Should be Empty:

Mexico Psilocybin Retreat