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1. Welcome

2. Participant Info

3. Personal Background

Have you taken psychedelics previously? If yes, in what context have you experienced psychedelics?
How would you rate your level of experience with psychedelics and altered states of consciousness?
Which of the following psychedelics have you taken?

4. Mental health

Are you currently taking any of the following medications?
Have you ever received a psychiatric diagnosis of any of the following?
Have you ever been diagnosed with the following psychiatric conditions
Have you ever been experiencing any of the following?
Have you ever been experiencing any of the following?
Have you at any point in the past experienced any of the following?
Are you currently experiencing health problems in any of the following domains?

Good faith statement: 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.

5. Physical health

Thank you for completing and submitting your health form. We will review your response and schedule a psychological screening with you. After screening, we will get back to you as soon as possible to confirm your eligibility for participation in our programs. ​We are looking forward to meeting you and working with you in The Netherlands. ​Kind regards, the ETI team

To join a retreat, you first have to complete the health questionnaire below. This form is to determine if this retreat is safe for you and if it suits you. The questions can also help you prepare.

After completing and submitting your health form, we will get in touch with you, after which you can book your preferred retreat date and complete payment. 

 

After your eligibility is confirmed, you will receive an email from us with an invitation for the psychological and/or the psychiatric intake. This call is to get to know you personally, and to see if the program is the right match for you. You will also learn how to best prepare for the retreat and you will also get more detailed information about the program.

 

If we decide the psychedelic assisted program is not a good match for you, you will be reimbursed and will only have to pay for the psychological intake (165 euro). 

 

Please answer all questions below to the best of your knowledge. It will help us guide and support you during your experience.

To join a retreat, you first have to complete the health questionnaire below. This form is to determine if this retreat is safe for you and if it suits you. The questions can also help you prepare.

After completing and submitting your health form, we will get in touch with you, after which you can book your preferred retreat date and complete payment. 

 

After your eligibility is confirmed, you will receive an email from us with an invitation for the psychological and/or the psychiatric intake. This call is to get to know you personally, and to see if the program is the right match for you. You will also learn how to best prepare for the retreat and you will also get more detailed information about the program.

 

If we decide the psychedelic assisted program is not a good match for you, you will be reimbursed and will only have to pay for the psychological intake (165 euro). 

 

Please answer all questions below to the best of your knowledge. It will help us guide and support you during your experience.

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Health screening form

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