November Boulder Retreat Application
November 6–8, 2026 · Boulder, Colorado. A retreat for adults 21+ from all backgrounds with Dr. LeTa Jussila, DAOM, weaving Chinese medicine, psilocybin, qigong and embodied integration. No healthcare or Chinese medicine experience is required. This initial application begins a conversation. It is not a medical screening, confirmation of acceptance or reservation, and no payment is collected here. Please do not include diagnoses, medications or detailed personal health or trauma history. Eligibility screening takes place separately.
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
City and State/Country
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Are you available in Boulder November 6–8, 2026?
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Yes
Unsure
No
Are you age 21 or older?
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Yes
No
What draws you to this retreat? (Please keep this general and avoid medical details.)
What questions would you like to discuss?
Your sliding-scale preference (all rates include the same retreat; no explanation is needed)
$2,000 Supported — when the full cost would significantly stretch your resources
$2,500 Sustaining — when you can cover the retreat while meeting everyday commitments
$3,000 Community Support — encouraged when you can comfortably meet your everyday needs
Discuss with me
Optional private care — select your interests (booked separately)
$795 Deep Preparation + Integration Package
Thursday private appointment
Monday private appointment
Unsure
None
I understand this application does not guarantee acceptance and a separate eligibility review is required.
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I acknowledge
I understand travel and lodging are excluded, and private appointments cost extra.
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I acknowledge
I understand the $1,000 deposit and remaining balance due October 7, 2026 for the November 6–8 retreat are subject to eligibility and the published cancellation/refund policy. I will review the written service and cost details before paying Haus of Potential, LLC through Stripe.
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I acknowledge
I agree to be contacted about my application.
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I agree
Send my application
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