Thank you for your interest in Homecoming our Psilocybin Retreat & Integration programme.

Note that the in person retreat dates are 30th September to 4th October 2024.

Please complete this form fully and honestly. All personal information is strictly confidential and will be treated securely.

Thank you,
Naz & Rachel

Co-Founders, Women are the Medicine

About you and your current situation

First Name *

Last Name *

Date of birth *

Email *

Phone *

What is your current occupation? *

Country of residence *

Country

Afghanistan
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Virgin Islands, U.S.
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What is your timezone? *

What are the three biggest changes you want to make in your life? (This could be in your business/career, your relationships, health/wellbeing, finances, spiritual development, your environment...) *

What would you like to contribute to the world? *

What are the biggest obstacles holding you back? *

You and Psychedelics

Please provide a brief summary of your history with psychedelics (if applicable), and future intentions regarding working with these medicines.

If you would rather discuss the information in this section with us in person, we can do so on our Discovery Call.

What's your history (if any) with psychedelics?

Why are you feeling called to work with psychedelics now, at this point in your life? What is your underlying intention?

Medical Declaration

How would you rate your current physical health?

Excellent

Good

Satisfactory

Unsatisfactory

Poor

Do you experience issues with any of the following?

Sleep

Appetite (under or over eating)

Chronic Pain

Headaches or Migraines

None of the above

How would you rate your overall mental health?

Excellent

Good

Satisfactory

Unsatisfactory

Poor

Are you currently experiencing any of the following? Please tick any that apply

Overwhelming sadness or grief

Anxiety

OCD

Panic Attacks

Phobias

None of the above

Are you currently taking (or in the last 6 months taken) any form of prescription medication? *

YES
NO
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If you answered yes to the last question, please detail what type(s) of medication with the BRAND name and how long you have been taking each

Have you previously accessed mental health therapies/services (e.g. psychotherapy, psychiatric services)? *

YES
NO
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If you answered yes to the last question, please detail what type(s) of mental health therapies/services you received and approximate dates (if more than once, please give dates for each) Please also confirm if you have ever been prescribed psychiatric medication - YES/NO, and if YES give details

Potential Contraindications

It's important to recognise that, as with any compounds taken medicinally, there are both physiological and psychological conditions which need to be screened out when it comes to psychoactive substance use.

Not all of these contraindications rule out the use of psychedelics - they do however need to be considered very carefully, as they can cause serious long-term damage if not acknowledged before going into a psychedelic experience.

Possible Contraindications - please select any/all of the following that apply to you:

Personal history of schizophrenia

Personal history of bipolar disorder

Personal history of severe depression

Family medical history of schizophrenia or bipolar disorder

Active suicidal ideation or previous attempts

Major emotional dysregulation

Currently taking SSRI or MAOI medication

Very high blood pressure

Very low blood pressure

Heart arrhythmia or irregular heart beat

Cardiac or coronary issues

Personal or family history of epilepsy/seizures

None of the above

Do you have a personal history of physical, developmental/childhood, or mental trauma? If yes, please be aware we will need to discuss this in more detail to assess your suitability for using psychedelics.

Finally, is there anything else you'd like me to know about you in terms of your physical, mental, emotional, relational, professional and spiritual health?

Retreat Requirements and Preferences

Please let us know your preferences for your room selection and any dietary (or other requirements you may need)

Please note that our venue has an upper level that is accessed by stairs

Please let us know any dietary requirements or restrictions we should be aware of. Do you have any dietary allergies and/or intolerances? Do you have any other requirements? *

Your preferences for room choice and payment - please select one of each. *

Solo Room
Shared twin
Pay in Full
Payment plan
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I hereby confirm that, to the best of my knowledge, the provided information is true and accurate.

I agree that by providing my email and phone number, I consent to receive email and text messages from Women are the Medicine. in relation to my application.