Name

First Name

Last Name

Your phone number *

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Next of Kin *

First Name

Last Name

Next of kin phone number *

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Have you ever been diagnosed with any of these conditions or experienced these symptoms?

Please mark accordingly.

Depression

Anxiety

Bipolar disorder

Personality disorder (please specify in the question below)

Fibromyalgia

History of self harm injury

Eating Disorder

Suicidal attempts

Schizophrenia

Psychotic symptoms

Behavioural or substance addiction

Substance abuse

PTSD

Cardiovascular disease / Concerning Heart Problems

Other (please specify in the question below)

None of the above

How did you hear about The Grief Space / Rooted Healing / Earth Medicine? *

First Name

Last Name

Do you sign and agree to the following statement? *

Wherein “I” refers to “You”, the participant of the retreat: “I am taking these psilocybin-containing truffles of my own volition. I acknowledge that no substance is entirely risk-free and that I am familiar and comfortable with the risks of psilocybin truffles. I understand that the retreat is not intended as a substitute for medical or psychotherapeutic care. I understand that I undertake other activities, including breathwork, dance, meditation, yoga, etc. at my own risk. I have read and agree to the conditions with regards to your Covid and general cancellation policies. I certify that all information provided on this form is true and complete. I understand that the admission to the retreat is based on some of the information provided on this form to ensure the safety of all participants and that any untruthful or inaccurate answers could lead to risks to myself or other participants.

Yes I agree

Privacy Statement *

Your details, information entered and contact details are strictly confidential. They will only be kept within the Rooted Healing organisation to decide on your suitability for our retreats. Choose yes if you agree to the storing and processing of your data.

Yes I agree