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Intake Application


The information below must be filled out to secure your spot. Providing this information is vital for ensuring your safety, comfort, and optimal experience during your upcoming psilocybin retreat with us. The details you provide will remain strictly confidential and will be used solely by our experienced staff to ensure the best possible care for you.

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Intake Information

To ensure the safety of all participants and the safety of all involved, I agree to answer the following questions with the utmost integrity and complete honesty
e.g. Ashwagandha, 5-HTP, St. John’s Wort
Check any symptoms that you are currently experience or have recently experienced:
Including, but not limited to: schizophrenia, manic depression, bipolar, borderline personality disorder, personality or dissociative disorders.
Are you currently experiencing or in the last five (5) years have you experienced any of the following?
Do you have any history or any family history of the following:
e.g. morphine, ketamine, cocaine, heroin, amphetamines, GHB, opioids, painkillers, and/or other prescription drugs.
e.g. history of brain tumor, pituitary disorder, epilepsy, dementia, amyotrophic lateral sclerosis, parkinson’s disease, multiple sclerosis.
All answers will be kept confidential.
This includes, but is not limited to: ayahuasca, cannabis, cocaine, DMT, Iboga/ibogaine, Ketamine, LSD, MDMA, psilocybin mushrooms, etc.

Liability Waiver & Consent

I understand that all attendees are asked to complete this Intake Form in full. I understand this information will only be used to allow ONE Retreats (Fractal Journeys LTD.) and its facilitators, officers, directors, employees, contractors, agents, and/or representatives (Team) to assess whether each prospective attendee’s participation will make the Retreat a safe and productive experience for all. I understand the screening process enables ONE Retreats (Fractal Journeys LTD.) to be informed of physical and mental health conditions that would prevent my safe participation in our retreats. I understand that ONE Retreats (Fractal Journeys LTD.) does not provide any health care services, and that any screenings performed are not medical evaluations, nor are they intended to assess any individual’s risk of experiencing side effects or identify what those specific side effects may be.
I understand that ONE Retreats (Fractal Journeys LTD.) services are not therapy or psychological counseling and are not a substitute for the treatments or services ordinarily provided by health care professionals for physiological or psychological complaints. If I need or desire medical treatment, therapy, or psychological counseling, I will seek it from a licensed provider. I am well physically, psychologically, and emotionally, and I commit to being responsible for my own well-being during the course of any services received.
I agree that these services aren’t designed to treat any person for any physical or mental condition or illness. ONE Retreats (Fractal Journeys LTD.) and the Facilitator(s) are not practicing medicine, diagnosing, curing, or treating disease or illnesses or administering, prescribing, or providing psychedelics, prescription drugs, or illegal substances.
I understand that ONE Retreats (Fractal Journeys LTD.) and the Facilitator(s), are not my therapist, counselor, or psychotherapist. Further, I agree to notify ONE Retreats (Fractal Journeys LTD.) and the Facilitator(s) immediately if any of the representations I made change. I also agree that I understand that no illegal substances will be provided by ONE Retreats (Fractal Journeys LTD.).
I have voluntarily disclosed all of the information contained in my responses on this Intake Form, and I authorize ONE Retreats (Fractal Journeys LTD.) to share my responses with its Team for the limited purposes described above. I understand that neither Rose ONE Retreats nor its Team will disclose my Responses to any third party unless I specifically authorize them to do so. I understand that neither ONE Retreats (Fractal Journeys LTD.) nor its Team will retain my Responses after concluding the screening process and Retreat.
I acknowledge that I am executing an authorization via electronic signature and I acknowledge that my electronic signature on this form has the same force and legal effect as my physically-handwritten signature would. I certify and agree that all information I have provided is true and correct and I consent to all terms and understandings above.