InwardBound Private Psilocybin Retreat Programme

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.

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1 Accommodation Options

Select a price.

€6,000.00 – Private 4-day Retreat Programme (3+ Participants, price per person VAT Included)

€7,000.00 – Private 4-day Retreat Programme (2 Participants, price per person VAT Included)

€11,000.00 – Private 4-day Retreat Programme (Single Participant VAT Included)

2 Participant Info

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 *
Country of residence *
Mobile phone number with country code *
Gender *
Application Form	I have already completed an InwardBound application formIf yes, please skip this section
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.

3 Retreat Preferences

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
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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