We provide support for sacred and intentional work with psychedelics

Hamptons Healing Retreat Application

All information is confidential.

Please respond truthfully, as there is zero judgment here. It is essential for us to know more about you before doing this work together, in order to ensure the greatest amount of safety and support for your experience. Thank you so much for your honesty.

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth (Month, Day, Year)

Have you ever worked with plant medicine before? If so, please give us more details.

Are you currently taking any medications (prescription or over the counter)? If yes, what do you take and what dose?

Are you currently struggling with an addiction or drug/alcohol dependence? If yes, please tell us more.

Have you ever received a diagnosis of bipolar I or bipolar II? If yes, please tell us more.

Have you ever had a psychotic episode or received a schizophrenia diagnosis? If yes, please tell us more.

Have you ever received a personality disorder diagnosis? If yes, please tell us more.

Do you struggle with anxiety? Have you ever had a panic attack? If yes, please tell us more.

Do you have any food allergies or dietary restrictions?

Do you have any food preferences?

What is your intention for this retreat?

Is there anything else you would like us to know?

I certify that the above information is correct. I have accurately, honestly, and fully represented myself and my medical, psychiatric, or psychological conditions.

Participant Name

First Name

Last Name

Today's Date

YYYY

Hamptons Healing Retreat Application

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