Name
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First Name
Last Name
Email
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Phone
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Country
(###)
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Date of birth
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MM
DD
YYYY
Program
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Personal Journey
Small Group Retreat
Psychedelic Practitioner Training
Please share with us your desire for and intention to go on a psychedelic retreat?
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Please tell us about any significant life events that have shaped who you are today?
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Please tell us more about any spiritual or contemplative practices that you find beneficial to your mental, physical or spiritual well-being?
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How are the support networks in your life?
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Have you taken psychedelics previously? If yes, in what context have you experienced psychedelics?
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No - I have not taken psychedelics
Yes - in a recreational context
Yes - in a ceremonial / intentional context
Yes - in a clinical trial context
Other
How would you rate your level of experience with psychedelics and altered states of consciousness?
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No experience
Relatively inexperienced
Moderately experienced
Very experienced
Which of the following psychedelics have you taken?
Would you describe any of your experiences with these substances as unpleasant or challenging?
Please tell us about your past and present use of other psychoactive substances, including legal ones.
Are you currently taking any of the following medications?
Have you ever received a psychiatric diagnosis of any of the following?
Do you have any close relatives (parents, children, siblings) with a history of psychosis, schizophrenia or bipolar disorder?
Have you ever been diagnosed with the following psychiatric conditions?
Have you ever been prescribed or taken medication for mental health or behavioural difficulties?
Have you ever been experiencing any of the following?
Have you ever been experiencing any of the following?
Please share as much as you can about what you are experiencing.
Have you at any point in the past experienced any of the following?
Have you ever had any professional therapeutic support, such as counseling, psychotherapy, group therapy, or psychiatric treatment?
Do you have a sense of what potentially contributes to any difficulties you may be experiencing (e.g. triggers, stressors)?
Are you currently experiencing health problems in any of the following domains?
Please tell us more about your general physical health. Do you have any medical conditions that we need to be aware of?
Are you using any medications for your physical health?
Are you taking any supplements, herbal remedies or alternative medicines?
How did you hear about ETI?
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Comments, Special Needs, or Additional Access Requirements
Dietary Requirements
Emergency Contact Information
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Is there anything you feel we should know about you that has not been asked about previously?
I hereby agree that if ETI concludes after the intake, the psychedelic-assisted program is not a good match for me, I will pay for the psychological intake (165 euros ex VAT).
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I have provided full and honest responses to the questions in this questionnaire and will inform the Experiential Training Institute team as soon as possible, and well in advance of the retreat, of any relevant changes - including new diagnoses, medications, or major life events. I understand that by withholding, downplaying or falsifying information, I could put myself at risk of harm. I understand that a relationship of openness and good faith with the facilitators creates the best possible foundation for a deep and valuable experience.
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