Application Form: Journey with Tish
Thank you for completing this form! I look forward to journey with you!
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Email *
Name & Last Name

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Please share your social handles (IG/FB/Website)
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Best Email
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How did you hear about my offerings?
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What type of offering are you interested in?
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What type of medicine would you like to work with?
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How much are you looking to invest in your journey?
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Share a little about yourself? How is your'e mental, emotional and physical wellbeing? Please describe any trauma(s) or abuse that you have experienced in your lifetime.
Have you ever journeyed with sacred plant medicine and or psychedelics and if so what types, where with whom and what was your experience?
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What is your intentions for working with me? Describe your intentions and goals for the retreat?
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Are you currently on any medications? If so please list them.
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Please list any other medications you have taken in the past. 
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Do you have any mental health conditions? If so please explain.
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Medical history information: *Please share if you have a history of any of the below:

Generalised Anxiety 
Social Anxiety 
Panic Attacks 
Clinical Depression 
Bipolar 1 
Bipolar 2 
Schizophrenia 
Psychosis Psychotic
Episodes Paranoia 
Personality Disorders 
Attempted Suicide 
Suicidal Ideation 
Self Harming 
Obsessive-Compulsive Disorder (OCD) 
Post-Traumatic Stress Disorder (PTSD) 
Attention Deficit Hyperactivity Disorder (ADHD) 
Autism Body Dysmorphia
Anorexia or Bulimia 
Gender Dysphoria 
Depersonalization or Dissociation 
Alcoholism or Other Drug Addictions
Describe your physical health; do you suffer of any of the below:

Traumatic Brain Injury 
Concussion(s) 
High Blood Pressure 
Circulatory Problems 
Past Stroke(s) 
Past Heart Attack(s) 
Past Aneurysm(s) 
Irregular Heartbeat 
Fainting 
Chronic Pain 
Diabetes 
Obesity 
Insomnia 
Sleep Apnea 
Irritable Bowel Syndrome 
Epilepsy or Seizures 
Thyroid Conditions 
Autoimmune Disorder 
Cancer Infectious Disease 
Other
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Anything else you would like to share?
Because these retreats involve the ingestion/utilisation of psychedelics and or plant medicine, I carefully screen each guest for their safety prior to attending a retreat. You hereby agree that all information you provide in the application is correct and current and that you have disclosed all physical and psychological conditions as well as all supplements, natural medicines and medications (prescription and over-the-counter) that you are taking. In some cases, you will be contacted personally by one of my team to ensure that you are prepared for the experience. Journey with Tish is not a medical facility and its owners, staff, employees and agents are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat disease or illnesses. Instead, I function as a guide and facilitate the effects that sacred plant medicine and psychedelics have on people.
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Accident and Release of Liability Agreement: 

I hereby assume all of the risks of participating in any/all activities associated with this event, including by way of example and not limitation, any risks that may arise that are not caused by direct negligence of the parties to be waived. I certify that I have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no mental or physical health-related reasons or problems which preclude my participation in this activity. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I waive, release, and discharge from any and all liability, including but not limited to, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, the following entities or persons: Journey with Tish, support team, volunteers, representatives, and integration guides ; (B) Indemnify, hold harmless, and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity. I acknowledge that Journeys with Tish is not responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I acknowledge that this activity may involve a test of a person’s physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but are also present for employees. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I certify that I have read this document and I fully understand its content. I am aware that this is a release of liability and a contract and I agree to it of my own free will.
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Thanks for filling in this form, once your application is reviewed we will be in contact soon about the next steps!
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