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Email *
Who may we thank for referring you. *
Do you have a spiritual practice? If so, please describe.* *
What Are Your Intentions/Goals For This Retreat *
Please provide last date used
Please describe
Please list allergies
If yes, please provide details
If yes, please provide details
If yes, please list them all
Do you have any dietary restrictions? * No Yes
If yes, please provide details
History of hospitalization: Have you ever been seen in a psychiatric emergency or been hospitalized for having a break of any kind? If so, when was it, and for how long? Have you ever been court-ordered to work with a psychiatrist or psychologist? If yes, what was the circumstance? * No Yes
History of Medication: Have you ever been prescribed medication to manage your psychological state? If yes, then which medications and for how long? Why did you discontinue using them? * No Yes
History of Mania or Psychosis: Do you have a history of mania or psychosis? If yes, when was the diagnosis? Has anyone in your immediate family been diagnosed with mania or psychosis? * No Yes
Depression history: Are you currently experiencing depression? If so, how severe and for how long? Have you been seeing a mental health professional to help them with your depression? What do you feel is causing the depression? Have you had depression in the past? If so, then how severe and for how long? Have you ever taken medication for depression or been advised to take medication for depression? * No Yes
Anxiety history: Are you currently experiencing anxiety? If so, how severe and for how long? Have you been seeing a mental health professional to help them with your anxiety? What do you feel is causing the anxiety? Have you had anxiety in the past? If so, then how severe and for how long? Have you ever taken medication for anxiety or been advised to take anxiety medication? * No Yes
Suicide history: Are you currently suicidal? Have you ever attempted suicide before? Have you ever had suicidal thoughts? If yes, then when and for how long? * No Yes
Explanations for Psychiatric Questions:
Have you experienced or been witness to a traumatic event? Can you describe what happened? * No Yes
How has this traumatic experience affected you? Do you have flashbacks, nightmares, or fear that arises due to the event? * No Yes
What emotions, if any, came up as a response to the trauma? * Fear Sadness Anger Confusion Other
How mild, moderate, or severe would you say your trauma is? Does the trauma still have you in a raw and vulnerable place at this moment in your life? * Mild Moderate Severe
Have you ever reached out for professional mental health support to process the trauma? Has it been supportive? * No Yes
Are there any words, language, sounds, songs, touch, gender, or anything else that you are aware of that triggers the trauma for you? * No Yes
Is there anything that we should know to best support you? * No Yes
Explanations for Trauma Questions:
I have read and understand the above contraindicated drugs and medications. * No Yes
Please list any medications from the above 2 lists or other medications not listed previously.
I have read and understand the above contraindicated drugs and medications and have previously listed any and all medications that I am taking. * No Yes
I have read, understand and agree to the above statements regarding marijuana? * No Yes
Dietary allergies: Do you have any allergies to any specific foods or ingredients? * No Yes
Touch: Do you have any aversions to touch? If yes, what touch? Do you have any aversions to hugs? * No Yes
Fragrances: Do you have any allergies or aversions to scents? * No Yes
not agree) them.
Animals: Do you have aversions or allergies to animals? If yes, which ones? * No Yes
Phobias/fears: Do you have any fears or phobias? * No Yes
Aversions: Do you have any aversions to anything else (lights, sounds, language, gender, etc.)? * No Yes
Concerns: Do you have any concerns about their stay with you or the experience? * No Yes
Additional Information: Is there anything else you would like you to know or disclose? * No Yes
Explanations for Preference Questions:
I have read, understand and agree to the above mentioned Code of Conduct and Sexual Integrity Agreement for attending this event * No Yes
Have have read and understood the above contraindications. I understand that taking other drugs or herbs may be harmful to my health. If I need to stop a prescribed medication I will ensure it is done safely and consult my physician if needed. * No Yes Third Choice
You agree that you are in physical and mental condition appropriate to the activities described in the event, that you agree to participate at your own risk, and that we cannot accept liability for any accident or injury. * No Yes Third Choice
Nondisclosure Agreement: By participating in this event you agree that you will not disclose the identities or actions conducted by any participant during the event without their expressed permission. * No Yes Third Choice
Please indicate this form was filled out honestly and to the best of your ability. * No Yes Third Choice
You will not disclose the event's location without permission from your host and the facilitators. (I understand and agree) * No Yes Third Choice
If you wish to invite someone to this event please get permission from your host or the facilitators before sharing any information sent by them. If you wish to invite someone to this event please get permission from your host and/or the facilitators before sharing any information sent by them. (I understand and agree) * No Yes Third Choice