Journey to Self Retreat Application
1. Fill Out The Application: Fill out the application form below as accurately as you can. Once you have submitted your application, we will contact you to schedule a call with someone from our team.

2. Confirm your spot: Once accepted, confirm your spot by making your 50% deposit. We will send you a preparation packet covering retreat information and some recommended exercises to mentally prepare you for the retreat.

Please take the time to fill out the application as honestly and accurately as you can. This information helps us assess your suitability for the retreat on a basic safety level, and to prepare and accommodate for you and the other guests at the retreat.

All the information you provide on the form will be kept strictly confidential.
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Full Name *
Email *
Date of Birth *
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Phone Number *
Gender
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Hometown/City *
Occupation *
Emergency Contact (Name and Phone Number) *
Do you have access to Zoom, Skype, FaceTime? *
Required
How did you hear about the Journey to Self Retreat? *
What are your motivations for attending the Journey to Self Retreat? *
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) *
Has anyone in your family suffered from or had any history of schizophrenia, psychosis, bipolar disorder, or any other psychotic disorder? If yes, please provide details. *
Tell us about any addictions, past or present. *
Are you currently taking any prescription medication? If yes, please provide details, including dosage, frequency of use and how long you have been taking them. (Including but not limited to antidepressants, SSRIs, blood pressure medication, mood stabilizers, benzodiazepines or other anti-anxiety medications, pain management, or opioid replacement therapies.   *
Are you currently taking any supplement medication, including natural herbs? If yes, please list all supplements.
Tell us about any physical or mental limitations and conditions that may limit your mobility or compromise your health. *
Please check health conditions that apply to you: *
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Tell us about your past and present use of both legal and illegal substances (alcohol, nicotine, caffeine, cannabis, MDMA, ketamine, LSD, psilocybin, etc) *
Do you have any experience with psychedelic substances? If yes, please describe including the contexts they were taken in. *
Tell us about your experience with related practices or other experiences of non-ordinary forms of awareness e.g. meditation, yoga, breathwork, sound healing, cacao ceremony, time spent out in nature. *
Do you have any dietary restrictions or food allergies? *
Select your accommodation preference *
If you are interested in a healing bodywork session with Nancy Rubio, please select day and time below?
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Is there anything else you would like our team to know about you when considering your application?
I certify that all information provided on this form is true, complete and accurate. I understand that admission to the Journey to Self Retreat is based, in part, on the information provided on this form. I understand that the information provided must be truthful and accurate to ensure the safety of myself and other retreat participants, and that falsifying or misrepresenting this information could endanger myself or other retreat participants. I understand that the Journey to Self Retreat is not intended as a substitute for medical or psychotherapeutic care. *
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If you have any additional inquiries you would like to explore, please list them here.
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