Application Form

InwardBound Costa Rica 5 day Small Group Retreat January 2026

January 22 - 26, 2026

- With Rob Ó Cobhthaigh (Psychotherapist) and Julia Gantner (Psychotherapist)

* These fields are required

Fully booked. Join the waiting list.

First Name *
Last Name *
Email *
Country of residence *
Age *
WhatsApp number with INTERNATIONAL DIALLING CODE *
Gender *
Motivations *	Why do you want to attend an InwardBound psychedelic therapy programme?
Are you currently taking the following drugs. Please answer yes or no.
SSRIs? (Antidepressants that act on serotonin) E.g. escitalopram (Lexapro), citalopram (Cipramil), sertraline (Lustral), fluoxetine (Prozac/Oxactin), paroxetine (Seroxat) *
SNRIs e.g. duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pritiq), levomilnacipran (Fetzima) *
Anti psychotic medication *
Do you have any of the following conditions: uncontrolled hypertension, aneurysms, heart disease, or arrhythmias such as Wolff-Parkinson-White Syndrome? If so, please give details *
Do you or in the last 10 years have you suffered from fits, seizures or epilepsy? *
Do you have any physical or other disability? If so, please give details *
Have you ever had a serious head injury? If so, give details *
Have you had or currently have cancer? If so, please give details
Are you currently suffering from severe stress or burnout? If so, please give details
I currently or have had a history of alcohol abuse? If so, please give details
Are you now or have you ever been diagnosed with a psychiatric illness? If so, please give details *
Have you ever had a manic episode/do you have bi polar ? If so, please give details *
Do you or any of your family members have a history of psychosis/schizophrenia? If so, please give details *
Have you ever attempted suicide, felt suicidal or had suicidal ideation in the last 5 years? If so, when and please give details *
Are you in going through a major life crisis? Are you going though a recent major stressful life event that could be very challenging e.g. bereavement/breakup. If so, please give details *
Do you have a immediate family member (parent/sibling) with bipolar, schizophrenia or a personality disorder? If so, please give details. *
WhatsApp Mobile Number with International code
Are you on any medications? If so, what are they for and what is the dose?
Do you have any mental health/physical health/medical conditions? If so, what?

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