Intimate Upshift - Being the Change RetreatMay, 05. - 09. 2025 Thanks for your interest in our retreat. Please fill out the form for your application. Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Date of Birth MM DD YYYY Do you have any ongoing health issues or medical conditions? Yes No If yes, please specify: Are you currently on any medications? Yes No If so, kindly provice a list of all the medications and their intended uses: Do you experience any allergic reactions Yes No If so, kindly provide details: Have you had any operations within the past five years Yes No If so, kindly indicate: Do you have any heart-related problems (e.g. hypertension, cardiac conditions)? Yes No If so, kindly provide details: Have you ever received a diagnosis for mental health issue? Yes No If so, please provide details Have you gone through any major trauma or stressful events in the past year? Yes No If so, kindly provide details: Have you ever struggled with substance abuse or addiction in the past? Yes No If the answer is yes, please elaborate: Have you ever had any negative responses to psychedelics or other substances? Yes No If so, kindly provide details: What captivates you about being a part of our psychedelic retreat? Have you tried any psychedelics in the past? Yes No Do you possess any knowledge or background in self-development, therapy, or shamanic traditions? Are you connected to spirituality or nature in any way and if so how? Do you feel comfortable taking part in group activities and discussions? Yes No Are there any particular concerns or questions you would like to address regarding the retreat? What made you aware of our psychedelic retreat? Familiy/Friends Social Media Online Search Advertisement Other What influenced your decision to consider this retreat? Testimonials/Reviews Program Details Price Other Are you interested in receiving updates on upcoming retreats and events? Yes No Do you have any specific dietary needs or preferences? Are there any physical limitations or special requirements we should be aware of? Yes No If so, kindly provide details: Do you have any other details that you think are significant for us to know in order to make your experience as positive as possible? I confirm that the information given is correct and comprehensive to the best of my understanding. Yes No I am aware that participating in a psychedelic retreat comes with certain risks and I am willing to comply with all guidelines and instructions provided by the retreat organizers. Yes No Thank you for your application for participation in our psychedelic retreat. We will review your application and get back to you soon. If you have any immediate questions, please feel free to contact us at info@brithinganancientfuture.com.
