Small Group Retreat: 4 day 8th – 11th November Netherlands

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

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Accommodation Options

Select a price.

Sold Out

€3,999.00 – €3999 per person, private room

Number of Guests:

Sold Out

€3,799.00 – €3799 per person sharing a room

Number of Guests:

People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

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

Participant Info

First Name *
Last Name *
Email *
Nationality *
Country of residence *
Age *
WhatsApp number with INTERNATIONAL DIALLING CODE *
Gender *
Motivations *	Why do you want to attend an InwardBound psychedelic therapy programme?
Medications *	Medications 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 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 *
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.
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

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 None of the above
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 have any physical or other disability? 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 *
Have you ever been diagnosed with a personality disorder? 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 been an in/out patient in any form of psychiatric hospital? If so, please give details *
Have you self-harmed or had strong urges to self -harm in the past 3 years? 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 *
Have you ever had an adverse reaction to a psychedelic substance? If so, please give details *
In the event of this retreat being cancelled due to government policy on infectious diseases, I agree that my reservation will be transferred to an alternative retreat date? *	We will give you choice over which retreat dates you can transfer your booking to
How did you hear about the Inwardbound retreats? *
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
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products. Separate payment of €50.00 per person to be arranged with the center.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

Payment

Payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products
Separate payment of €50.00 per person to be arranged with the center.

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