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Application Form

Please take the time to fill out the application as honestly and accurately as you can. This information helps us to assess your suitability for the retreat on a basic safety level, and to prepare and accommodate for you and the other guests on retreat. Once you have submitted your application, we will contact you to schedule a call with one of our team.

All the information you provide on the form will be kept strictly confidential.

Apply

Your Full Name *

Your Email *

Date of Birth *

Phone Number

Your Gender

Male

Female

Other

Location

Occupation

Skype or Zoom *

How did you hear about us?

What are your motivations? *

Tell us about any personal past or present mental health conditions (including depression, anxiety, psychosis, bipolar disorder, substance abuse, behavioural addictions, eating disorders and PTSD). *

Has anyone in your family suffered from or had a history of schizophrenia, psychosis, bipolar disorder, or any other psychotic disorder? If yes, please provide details. *

Tell me about any addictions, past or present. *

Are you currently taking any medication? If yes, please provide details, including dosage, frequency of use and how long you have been taking them. *

Including but not limited to; anti-depressants, SSRIs, blood pressure medications, mood stabilizers, benzodiazepines or other anti-anxiety medications, pain management, or opioid replacement therapies.

Tell me about any physical conditions that may limit your mobility or compromise your health, including low blood pressure or low blood sugar. *

Tell me about your past and present use of both legal and illegal substances (alcohol, nicotine, caffeine, cannabis, MDMA, ketamine, LSD, psilocybin etc.) *

Tell me about your experience with related practices or other experiences of non-ordinary forms of awareness e.g meditation, yoga, breathwork, sound healing, time spent in the wild. *

Do you have any dietary restrictions or food allergies? *

When would you like to have your session? *

In a month

Within 3 months

Within 6 months

Within a year

Not sure yet

Is there anything else you would like us to know?

I certify that all information provided on this form is true, complete and accurate. I understand that acceptance for a private session is based, in part, on the information provided on this form. I understand that the information provided must be truthful and accurate to ensure the safety of myself and other retreat participants, and that falsifying or misrepresenting this information could endanger myself or others. I understand that private psychedelic sessions are not intended as a substitute for medical or psychotherapeutic care. *

Yes

No

If you have any additional inquiries you would like to explore, please list them here.

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• Feel ready and prepared before your journey
• Cover bases of preparation at a glance
• Walk through with friend or group beforehand

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Free DIY Psychedelic Exploration Guide PDF

Feel ready and prepared before your journey. Cover bases of preparation at a glance. Walk through with friend or group beforehand

john [at] mapsofthemind.com

Maps Of The Mind Ltd.

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