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Thank you for signing up for a retreat with us. We have some questions for you, so that we can get to know you better to support you during your journey in the best way possible.

First name *

Last name *

Company

Email *

Phone *

Date of birth *

Streetname + number *

Zipcode *

City *

Do you have experience with psychedelics? *SelectYesNo

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? *SelectYesNo

Yes, that is: *

Are you currently taking any medications? *SelectYesNo

Yes, that is: *

Do you suffer from psychological problems? *SelectYesNo

Yes, that is: *

Do psychological problems run in the family? *SelectYesNo

Yes, that is: *

Do you suffer from heart problems or high blood pressure? *SelectYesNo

Are you pregnant or are you breastfeeding? *SelectYesNo

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? *

Can you tell us something about your background? *

Think of family, upbringing, what did you get from home

Are there recurring themes in the family line? *

Think health / family patterns / traumas / problems

Food-wise: what do you like to eat? *

Something you can really enjoy

And what would you rather not eat? *

Allergies, diet or conscious choices

Is there anything else that is good for us to know? *

What can help us make your experience as pleasant as possible for you

How did you find us *SelecteerLinkedInFamily / friendsInstagramOther

Other: *

Confirm *

• I have answered the above questions truthfully.

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