Name
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First Name
Last Name
Email
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Phone
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Country
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Country of residence
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What are you hoping to gain from a psilocybin experience and personalised programme?
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Please provide a clear brief of the experience you hope to co-create.
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What dates or time-window would you like to book your bespoke retreat?
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Please share any previous experiences you have had with psychoactive substances, including frequency and dose. How did these experiences affect you, both short + long term?
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Have you suffered in the past from any physical health conditions, illnesses, or complications? What is the biggest challenge to your physical health today?
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Are you currently using any medication? If yes, please list them, including dosage and frequency.
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Please share information regarding your current support network - friends, family, therapist etc. Who can you talk to about this experience?
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What are the greatest challenges you are dealing with currently?
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Can you share information regarding your childhood; did you deal with any trauma (such as emotional or psychological abuse, physical or emotional neglect, divorce or separation of your parents, parent or guardians with addictions...)?
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How have your childhood (T/t)raumas affected your adult life?
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Have you experiences trauma in your life otherwise? Such as natural disaster, accident, abuse, war zone... and how does this affect you now?
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What is your current home environment like?
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Have you ever been diagnosed with any of these conditions or experienced these symptoms? Please mark accordingly.
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If you marked any of the above, please share some information about the past & current state of the disease/symptoms. If you selected "Other" or "Personality Disorder", please share more information about it below.
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Do you have any first or second-degree relatives with schizophrenia, bipolar disorder, or any other psychotic disorder? If yes, please provide details.
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Do you have any experience with holistic practices such as Yoga, meditation, Qi Gong etc? Do you have a regular practice?
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What are your dietary requirements?
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Please state your Next of Kin (name, relationship, phone number with area code)
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Is there anything else you would like us to know to help us better support you throughout this process?
How did you hear about Rooted Healing?
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Do you sign and agree to the following statement?
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Wherein “I” refers to “You”, the participant of the retreat: “I am taking these psilocybin-containing truffles of my own volition. I acknowledge that no substance is entirely risk-free and that I am familiar and comfortable with the risks of psilocybin truffles.
I understand that the retreat is not intended as a substitute for medical or psychotherapeutic care.
I understand that I undertake other activities, including breathwork, dance, meditation, yoga, etc. at my own risk.
I have read and agree to the conditions with regards to your Covid and general cancellation policies.
I certify that all information provided on this form is true and complete. I understand that the admission to the retreat is based on some of the information provided on this form to ensure the safety of all participants and that any untruthful or inaccurate answers could lead to risks to myself or other participants.
Privacy Statement
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Your details, information entered and contact details are strictly confidential. They will only be kept within the Rooted Healing organisation to decide on your suitability for our retreats. Choose yes if you agree to the storing and processing of your data.
