Name
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First Name
Last Name
Email (please ensure this is correct)
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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 the Earth Medicine experience?
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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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Is there anything else you would like to share with us to help us understand how we can best support you?
What are your dietary requirements?
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Please provide your Next of Kin (name, relationship, number inc. area code)
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How did you hear about Rooted Healing / Earth Medicine?
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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.
