Individual/Couple Session Questionnaire
Hello and welcome! We’re thrilled to be working with you. Providing us with the following information helps us work with you on any issues that may come up.  We’re asking for complete honesty in responding to the questions and promise absolute discretion. EACH PARTICIPANT IS REQUIRED TO FILL OUT THIS FORM FOR HIMSELF/HERSELF/THEMSELF. Answer directly on the form. Thank you.

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Email *
Name (first & last) *
Phone (INCLUDE COUNTRY CODE) *
Add Kasham +351 913-903-785 to your contacts and please send your name/say hello to Kasham on Whatsapp.
We use this for fast communication and to make a group, if applicable. *
Age at time of session. *
How did you hear about us? (Please be specific) *
Required
Gender (preferred pronoun) *
Are you willing to share a double bed with another participant? (i.e. your friend, partner, spouse) If so, please indicate his/her name. *
Required
Which retreat/event date are you applying for? Please list the date you booked on Calendly. (If you have not booked via Calendly, please do so below before submitting as it has all available options.) 

 *
Which VENUE? (please see two links above for availability) *
If you have previously taken plant medicine or any substance that is a consciousness altering substance, please identify which plants or substances you have taken and the approximate date of your last experience. (If none, please type NONE.) Please share the context in which you took them, amount taken (if known), and how each medicine experience was for you. *
Tell us about any personal- past or present- mental health conditions (including depression, anxiety, psychosis, bipolar disorder, substance abuse, behavioral addictions, eating disorders and PTSD, etc). *
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 in the "other" line. *
Required
Tell us about any medications you're currently taking. Please provide details, including: dosage, frequency of use, primary reason, and how long you have been taking them. *
Tell us about any physical conditions that may limit your mobility or compromise your health, including low blood pressure or low blood sugar. *
In a few words please state your intention for joining this retreat. *
Food allergies/sensitivities (please be specific) *
Are you allergic to cats, dogs or both?
There is an animal(s) who lives at the location. They will not interfere with your process but are in (a blocked off) part of the center and outdoors.
 *
Are you now addicted to any drug or alcohol? *
We operate primarily in English. Are you comfortable with English enough to communicate your needs?  

(If you're not comfortable with English, most of our facilitators can communicate in multiple languages; PLEASE NOTE WHICH LANGUAGES you prefer to communicate in.)
*
I will/have pay my deposit (350€ per person) 
***Do not mention medicine. Simply put your first name and the start date of session.
THEN PLEASE SEND PROOF TO: Kasham (Telegram or Whatsapp) +351 9139-03-785  *
I've read & understand the Terms & Conditions, including the cancellation policy (See Section 2).
I will pay the balance in full:
 *
Emergency Contact info. (Please note name and contact info of someone we can disclose the type of medicine / retreat you are on. We will not contact this person unless it is an emergency.)
I (write your name in the response) have answered the above questions truthfully and state that my mental, emotional and physical health in no way impedes my taking medicines offered. I am NOT taking SSRI drugs, SNRI drugs or MAOI drugs at this time. I am taking these plant medicines and participating in the ceremony(ies) on the date(s) noted above, of my own free will and I take full responsibility for my participation.  *
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