Application
Complete this form to take the first step towards attending a Heroic Path to Light retreat. We will use your responses to best personalize your retreat experience. Please answer these questions as accurately as possible. All information is kept strictly confidential.
Anwani ya barua pepe *

What’s your First Name?

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What is your Last Name ? *

What's your email address?

(Please double-check you've entered it correctly!
We won't be able to contact you if there's a typo.)

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What's your date of birth? (Month Day, Year)

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Siku
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Mwezi
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Saa

What's your gender?

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What is your current occupation?

What is your phone number?

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Please provide full current mailing address

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How did you find Heroic Path to Light *
The cost of the 25-week program is $5000.  Please answer the question with one of the options listed below.  (All donations are tax deductible) *

Is there a specific problem you’d like to work on during the retreat?  If so, please describe it here.

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What do you hope to get from your retreat experience?

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Do you have any concerns regarding your retreat experience?

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Have you ever used sacred plant medicines before?

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What is your general level of comfort with altered states of consciousness?

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Extremely uncomfortable
Extremely comfortable
What is your general level of sensitivity to psychoactive substances?  
 

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(This can include substances like alcohol, caffeine, nicotine, prescription medications, supplements, over the counter medications, cannabis, and plant medicines.)
What is your level of sensitivity to sensory stimulus in general?  


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(Sensory stimulus may include loud sounds, bright lights, strong smells, large crowds of people, and other people's emotional states.)
Please describe your past and present use of psychoactive substances.  


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(This includes substances like alcohol, caffeine, nicotine, cannabis, psilocybin, ketamine, LSD, MDMA, etc.)
Tell us about your experience with spiritual practices including meditation, yoga, breathwork, acupuncture and any other contemplative or integrative practice.
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Please describe any experiences with therapy or mental health counseling, past or present.
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How would you describe your support network and their level of support? (family, friends, etc)
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Have you served in the military? *
Did you see combat?
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Were you physically wounded?
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Have you served as a first responder? *
Are you a Gold or White Star Family? *
(A Gold Star Family is one that has lost an immediate family member in the line of duty of military service. A White Star Family is one that has lost a military service member or first responder to suicide.)
Health and Safety

Please provide the name of an emergency contact (family member, friend, colleague, etc):


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(This person's information will only be used in the case of an emergency.)
Emergency contact phone number:
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Do you have any dietary restrictions or food allergies?
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What is your bodyweight? (in Pounds/lbs)

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Please tell us about any physical conditions that may limit your mobility or compromise your health.
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(Please be sure to let us know if you have low blood pressure or low blood sugar, any inflammatory bowel diseases such as Crohn's disease or IBS, or asthma.)
Are you currently using any prescription medications or herbal supplements? If yes, please list them along with the name, dose, frequency of use, and condition being treated.
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(Entheogenic sacraments can interact with many prescription medications and herbal supplements. These interactions can be dangerous and/or reduce the subjective effects of the sacrament.

To ensure your experience at a Heroic Path to Light retreat is safe and positive, it's very important to let us know about any and all medications you're taking.)


Please tell us about any past or present mental health conditions including depression, anxiety, bipolar disorder, psychosis, PTSD, substance abuse, behavioral addictions, eating disorders, etc.

(Regardless of a formal diagnosis, please list any mental health conditions you feel are relative to your application.)  
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Have you experienced significant grief or loss?
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(This could include the passing of a family member, friend, a pet, or any other significant life event that caused you grief or loss.)
Do you have a first-degree relative with schizophrenia, bipolar disorder, or any other psychotic disorder?
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(A first-degree relative is a parent or sibling.)
Do you have a second-degree relative with schizophrenia, bipolar disorder, or any other psychotic disorder?
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(A second-degree relative is an uncle, aunt, nephew, niece, grandparent, half-sibling, or double-cousin.)
Help us understand you better. 
When you were growing up, during the first 18 years of life:  

(These questions are personal so you do not have to respond if you do not feel comfortable; however, accurate answers to these questions help us create the most beneficial and safe retreat experience for everyone involved.)

Was your home environment abusive, unstable, or emotionally and/or psychologically hurtful?
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Did you feel neglected, or lack basic needs like clean clothes, food, and a sense of safety?
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Did you live with anyone who was a problem drinker, used street drugs, was frequently depressed, mentally ill, or went to prison?
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