Alma Healing Center Intake Form
Please provide the following information to help us coordinate for your arrival. We look forward to working with you! - the Alma team
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Full name *
Email address *
Telephone number (for Whatsapp, preferably) *
Age *
Nationality *
What are you interested in? *
Required
Where did you hear about Alma Healing Center? *
Required
Do you have any food allergies? *
If so, what are they?
What is your diet preference?
Clear selection
What are your reasons for participating in this retreat? What do you expect to get from the retreat? *
Will this be your first mushroom experience? *
Will this be your first experience with mind-altering / psychedelic substances? Please explain.
Do you need Spanish to English interpretation? *
Emergency Contact Information
In the case of an emergency, please let us know who you want us to contact for yo
Emergency Contact Name *
Relationship to you *
Emergency Contact Email *
Emergency Contact Phone Number *
Physical/Psychological/Health Condition
In this section, please highlight any physical or health condition that applies from the options below. This will help us make sure you are suited for the retreat.
Do you suffer from low blood sugar / hypoglycemia? *
Do you have a history of schizophrenia? Or does a member of your family? *
Physical or Health Condition you had or that you currently have *
Required
Psychological Condition *
Required
Are you currently taking or have your been prescribed any medications for any of the above psychological conditions? If so, please briefly describe below *
Are you currently taking or have you recently stopped taking anti-depressant medication? *
If so, please specify which medication *
Have you ever been diagnosed, treated, or self-identified with drug addiction/abuse? * *
If so, please provide us with some additional information about the types of drugs, date(s), or time span of addiction and your experience of any therapy or rehabilitation you have undergone to heal. *
Is there anything else you'd like to share with us?
Agreement
Please read the following section carefully. It is really important that you fully understand the text below.
I will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing. *
I will discontinue all use of recreational street drugs and non-prescribed pharmaceuticals prior to commencing with Alma Healing Center Retreats. I understand that many street and recreational drugs are strongly contraindicated with mushrooms and can be very dangerous when combined. *
I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when consuming mushrooms. *
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