Inwardbound Group Retreat: Netherlands 30th Sept

Please do not fill in this application form until you have booked an initial consultation call viaadmin@inwardbound.ie.

Please take your time in completing this application form. The information you supply is treated with the strictest confidence.

* These fields are required

1 Accommodation Options

Select a price.

€3,499.00 – €3,499 per person

€3,200.00 – €3,200 per person sharing a twin room with a friend or partner

2 Optional Items

Extra Integration Sessions with Psychotherapist

2 Integration Session are included in the Programme Price ( 1 group, 1 one-to-one - if you require more, you can order them here)

€200.00

Select quantity

Extra preparation sessions with Psychotherapist

2 preparation Session are included in the Programme Price ( 1 group, 1 one-to-one - If you require more, you can order them here)

€200.00

3 Extra Integration Sessions with a Psychotherapist

3 Extra Integration Sessions - Grounding somatic processing sessions helping clients to integrate their psychedelic experience

€500.00

3 Extra preparation sessions with Psychotherapist

1 session comes as standard. Please add this option if you feel you might need additional support

€500.00

3 Participant Info

	Send me a reminder if I don't register today
Inwardbound Pre-screening and Intake Form	Please take your time in completing this Pre-Screening Questionnaire. It is for your own safety that we require you to disclose as much detail about your medical history as possible. The information you supply is treated with the strictest confidence refer to Privacy Policy and ToS. We will do our best to accommodate Participants on InwardBound Retreats - subject to our Terms and Conditions. Please book an exploration call via admin@inwardbound.ie before filling in this application form to make sure you are a suitable candidate. InwardBound reserve the right to refuse participation if the safety or Participants may be compromised. Please provide all information that you feel is relevant. If you have any questions, please email admin@inwardbound.ie Any Participant who provides incorrect information or obscured details, may be endangering themselves and others and can be expelled from the retreat without question and without refund at the sole discretion of the Organiser. Once completed we will screen it and send on our full screening form and book you in for your consultation screening and preparation call.
First Name *
Last Name *
Email *
Nationality
Country of residence *
Age
Mobile phone number with country code
Gender *
Emergency Contact	Name and phone number of next of kin or close friend
Motivations	Why do you want to attend an InwardBound psychedelic therapy programme?
Medication and Supplements *	Medications and Supplements Please fill out this section of the form thoroughly. This retreat involves ingesting psilocybin, a drug that can interact dangerously with some other substances. The list below is not exhaustive, therefore it is imperative that you list all currently and recently used substances.
Are you currently taking or have you ever taken 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-convulsant or epileptic medication *
Anti psychotic medication *
Stimulants for recreational use or for treatment of ADHD or narcolepsy *
Anti-anxiety medication *
Medical Details	If you answered "yes" to any of the above medical conditions, please give relevant details here. Please be as specific as possible, letting us know when you came off the above medication and if you are currently on the above medication.
Special Diet
Dietary requirements
List allergies
Data Policy	I agree to my data being stored by InwardBoundPlease read our Privacy Policy
Disclosure	I confirm I have fully disclosed any information that may be relevant to my application. I understand that withholding any relevant information poses risks to my physical and psychological wellbeing.
Email newsletter	Please send me the InwardBound newsletter

4 Medical History

Medical Conditions	I medicate with over the counter supplements or pills. I medicate with tricyclic antidepressants (Amitriptyline, Anafranil, Asendin, Aventyl, Elavil, Endep, Norfranil, Norpramin, Pamelor, Sinequan, Surmontil, Tipramine, Tofranil, Vivactil), lithium, SSRIs, haloperidol, or MAOIs. I medicate with Ritonavir/Indinavir/Dronabinol. I use supplements that affect serotonergic function, e.g. 5-HTP, St John’s Wort. I am currently or recently using steroid or immunosuppressant medication. I have had an operation under general anaesthetic. I medicate with inhalers I am taking a contraceptive pill or HRT
Are you now or have you ever been diagnosed with a psychiatric illness? If so, please give details
Do you or any of your family members have a history of psychosis? If so, please give details *
Do you or any of your family members have a history of schizophrenia? If so, please give details *
Have you ever been diagnosed with a personality disorder? If so, please give details
Have you ever attempted suicide, felt suicidal or had suicidal ideation in the last 10 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
Terms and Conditions	I accept the terms and conditions.Please read the terms and conditions
Discount code
I am aware that withholding or misrepresenting any information relevant to this process can put me or others at risk and can prevent my participation on the retreat *	yes no

5 Payment

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Deposit	$0

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Inwardbound Group Retreat: Netherlands 30th Sept - 3rd Oct 2024 (4 days)

Inwardbound Group Retreat: Netherlands 30th Sept – 3rd Oct 2024 (4 days)

1 Accommodation Options

2 Optional Items

3 Participant Info

4 Medical History

5 Payment