First name *
Last name *
Company
Email *
Phone *
Streetname + number *
Zipcode *
City *
Do you have experience with psychedelics? * Select Yes No
If so, which and when was the last time? *
How has/have your experience(s) been with psychedelics? *
What is the reason you are registering for this retreat? *
What would you like to know, find out, learn, process? *
Do you ever use mind-altering drugs? * Select Yes No
Yes, that is: *
Are you currently taking any medications? * Select Yes No
Yes, that is: *
Do you suffer from psychological problems? * Select Yes No
Yes, that is: *
Do psychological problems run in the family? * Select Yes No
Yes, that is: *
Do you suffer from heart problems or high blood pressure? * Select Yes No
Are you pregnant or are you breastfeeding? * Select Yes No
What is your primary response to fear? *
What helped you the most at such a moment? *
Which loved ones that are important to you have passed away? *
What events in your life have left a deep impression on you? *
What are recurring patterns that hinder you? *
How did you find us * Selecteer LinkedIn Family / friends Instagram Other
Other: *