Statement of Psychological and Health Conditions

Statement of Psychological and Health Conditions

Alchemy of Touch and Intimacy 2025
The "Alchemy of Touch and Intimacy" retreat is dedicated to providing a safe and supportive environment for all participants. To ensure the well-being of everyone involved, we require participants to disclose any psychological or health conditions that may affect their participation in the retreat. This information will remain confidential and will only be used to provide appropriate support and accommodations as needed.

Please read and complete the following statement:

I, the undersigned, understand that participation in the "Alchemy of Touch and Intimacy" retreat involves engaging in various physical, emotional, and psychological activities. I affirm that the information provided below regarding my psychological and health conditions is accurate and complete to the best of my knowledge.
Name

First NameLast Name
Age
Sex/Gender

Cisgender maleTransgender maleNonbinary
1. Physical Health Conditions: Please list any current or past physical health conditions that may affect your participation in the retreat (e.g., heart conditions, diabetes, mobility issues, allergies):
2. Psychological Health Conditions: Please list any current or past psychological or mental health conditions that may affect your participation in the retreat (e.g., anxiety, depression, PTSD, bipolar disorder):
3. Medications: Please list any medications you are currently taking, including dosage and frequency:
4. Please list any allergies you have to food, medication, etc.
Emergency Contact
Emergency Contact

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Acknowledgements
5. Consent and Acknowledgment:

- I understand that the retreat facilitators are not responsible for managing my health conditions and that it is my responsibility to manage any medical or psychological needs I may have during the retreat.

- I acknowledge that it is my responsibility to inform the retreat facilitators of any changes to my health or psychological conditions prior to or during the retreat.

- I agree to seek appropriate medical or psychological care if needed during the retreat and to notify the facilitators immediately in the event of a health or psychological emergency.

By signing below, I confirm that I have read and understand the terms of this statement and that the information I have provided is accurate and complete.
Name

First NameLast Name
Signature

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Statement of Psychological and Health Conditions

Emergency Contact

Acknowledgements