Unity Immersion Retreat Application

CONFIDENTIAL APPLICATION
Unity Immersion Application
This questionnaire helps us understand your background, health and intentions.

All responses are held in strict confidence.
Personal information
Basic details so we know who you are and how to reach you.
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Email address
example@example.com
Phone number
Format: (000) 000-0000.
Country of residence

Physical health
We need a clear picture of your current physical health to assess safety and suitability for this experience.
Do you have any current or past medical diagnoses? *Include cardiovascular conditions, epilepsy, liver or kidney disease, cancer, autoimmune disorders, or any ongoing conditions.
Have you had any surgeries or hospitalizations in the past 2 years?
Are you currently pregnant, breastfeeding, or trying to conceive? *
Do you have a personal or family history of heart problems?

Medications & substances
Many substances — including common antidepressants and supplements — interact with psychedelic medicines. This information is essential for your safety.
Important: SSRIs, SNRIS, MAOIs, lithium, and stimulants can cause serious interactions. Please list everything, including vitamins and herbal supplements. Your honesty protects you.
List all current prescription medications *Include medication name, dose, and duration. Write 'None' if not applicable.
List all supplements, vitamins, or herbal remediesInclude St. John's Wort, 5-HTP, melatonin, Lion's Mane, etc.
Are you currently using any recreational substances? Includes cannabis, MDMA, cocaine, opioids, etc. Kept strictly confidential.
How many alcoholic drinks do you consume per week on average?

Describe your most significant psychedelic experience. What substance, what was the context, what did you encounter, how did you integrate it?
Have you ever had a difficult or destabilizing psychedelic experience?
If yes, please describe what happened and how you navigated it

Support network
Grounded support before and after a retreat is essential for integration and
lasting wellbeing.
Who is your primary support person? *
Do they know you are attending this retreat?*
Emergency contact name and phone number*
How would you describe your social support more broadly?
Do you have any post-retreat integration support in place?

If you are following a dieta or preparation protocol, how long have you been preparing?
Any other dietary details we should know about?
Do you have any physical accessibility needs or mobility considerations?
Do you have any sleep conditions we should be aware of? E.g. sleep apnea, sleepwalking, severe insomnia.

Agreements & consent
Please read and confirm each item before submitting. These agreements formthe foundation of our relationship and your safe participation.
Is there anything else you would like us to know about you? Anything that didn't fit elsewhere — context, concerns, questions, or what feels most important for us to understand about you right now.
Should be Empty:

Unity Immersion Application