Intake Form
Application for the Awakened Journey retreat program. This form uses 4 steps and includes health and safety screening. Please answer honestly and completely.
Step 1 of 4 — About You
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
City, Province/State
*
How did you hear about The Awakened Journey?
*
Step 2 of 4 — Your Journey
What brings you to this work right now? What feels stuck, incomplete, or ready to shift?
*
What have you already tried? Please include any work with a therapist, coach, somatic practitioner, or other healing modalities.
Have you worked with plant medicines or psychedelics before?
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Yes
No
Prefer to discuss on the call
If yes, what have you worked with, approximately when, and in what context (ceremonial, recreational, therapeutic)?
What would success look like 6 months after completing the program? Please be as specific as possible.
*
Step 3 of 4 — Readiness & Commitment
What in your life currently supports your ability to commit fully to this 4-month program, including active engagement before, during, and after ceremony? What might get in the way?
*
Is there any significant current life circumstance the facilitator should know before speaking with you, such as a major transition, loss, health challenge, or relationship shift?
*
If this feels like the right fit, are you in a position to make the investment?
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Yes
No
I’d like to discuss options
Step 4 of 4 — Health & Safety Screening
Personal or family history of psychosis, schizophrenia, or bipolar I disorder?
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Yes
No
Unsure
Currently taking any psychiatric medications?
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Yes
No
If yes, please list the medications you are currently taking
Currently pregnant or breastfeeding?
*
Yes
No
Any other relevant physical or mental health history you would like the facilitator to know?
Submit Application
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