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 * Profession * Layout Do you have a roommate? * Select an option Yes No Do you need a roommate? * Select an option Yes No Are you currently, or in the last month, taking any prescription medicines? If YES, list all medications, making sure to specify dosage and duration of use, as well as all reasons/conditions for all medications: * Do you have any medication allergies? If YES, list all allergies and reactions: * Do you have any food allergies or restrictions? If YES, list all allergies and reactions: * Do you have any known mushroom or plant medicine allergies? If YES, list all allergies and reactions: * Check any symptoms that you are currently experience or have recently experienced: * If you check any symptoms, please provide details, including dates and treatment(s): * Are you pregnant, planning to become pregnant and/or breastfeeding? * Do you have or have you ever had heart issues? If yes, please provide details, including dates and treatment(s): * Have you, or any member of your family, been diagnosed with or experienced depression, anxiety, post-traumatic stress, substance misuse, obsessive compulsive disorder, or an eating disorder? If yes, please provide details, including dates and treatment(s): * Are you currently experiencing or in the last five (5) years have you experienced any of the following? * If yes to any, please provide details, including dates and treatment(s): * Do you have or have you ever had any mental conditions which you feel has affected you in a less than optimal way? If yes, please provide details, including dates and treatment(s): * Have you ever received a diagnosis of Post traumatic stress disorder (PTSD): If yes, please provide details, including dates and treatment(s): * Do you have any history or any family history of the following: * If yes to any, please provide details, including dates and treatment(s): * Are you currently experiencing or in the last 24 months have you experienced severe or problematic drug and/or alcohol abuse. If yes, please provide details, including dates and treatment(s): *
e.g. morphine, ketamine, cocaine, heroin, amphetamines, GHB, opioids, painkillers, and/or other prescription drugs.
Have you seen in the past, or are you currently seeing, a therapist or a mental health professional? If yes, when was the last time you saw them and/or how often do you see them? * What are 3 words you would use to describe your childhood? * Do you have a relationship with a behavior or a substance that you would like to change? If yes, please describe: * Do you have any immediate concerns or pressing matters? If so, please describe * Who or what supports you and where do you turn for support? Can you discuss your feelings openly with these people and rely on them for support, resources, and strength? * Are they aware of your intention to participate in a journey and are they willing to support you during the integration period upon your return home? * When was the last time you used a recreational drug or psychedelic and what was the quantity? *
This includes, but is not limited to: ayahuasca, cannabis, cocaine, DMT, Iboga/ibogaine, Ketamine, LSD, MDMA, psilocybin mushrooms, etc.
Have you ever had a challenging experience with a psychedelic or recreational drug? If so, please describe: * What are your intentions (not expectations) for participating in this program, as it can be valuable for you to clarify the reasons you are doing this work? * Do you currently have a mindfulness practice (journaling/meditation, etc?) If so, please describe: * How do you nurture yourself and what are your self-care practices? * What do you want to learn about yourself? * How can this experience help you evolve into your higher self? * Is there anything else you would like us to be aware of or any specific questions you have? Liability Waiver & Consent Acknowledgement *
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 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 to be informed of physical and mental health conditions that would prevent my safe participation in our retreats. I understand that ONE Retreats 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 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 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 and the Facilitator(s), are not my therapist, counselor or psychotherapist. Further, I agree to notify ONE Retreats 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.
I have voluntarily disclosed all of the information contained in my responses on this Intake Form and I authorize ONE Retreats 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 nor its Team will retain my Responses after concluding the screening process and Retreat.