Small Group Retreat: 4 day 28th September- 1st October Netherlands

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 *
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 *
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.
Fellow Participants	Names of those who are attending the private retreat with you
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
Do you suffer from or in the last 5 years have you suffered from asthma, bronchitis and/or shortness of breath? If so, please give details
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 suffer from allergies including medical (drug), hay fever, peanuts, shellfish etc..? If so, please give details *
If yes: Have you ever had an anaphylactic reaction e.g. experienced swollen lips, difficulty breathing Do you carry an Epipen?
Have you fainted or collapsed in the last 5 years? If so, please give details
Do you have Diabetes?
If yes: Do you take insulin?
Have you ever had an episode of DKA (diabetic ketoacidosis) or a severe “hypo”?
Do you or in the last 10 years have you suffered from fits, seizures or epilepsy? *
If yes: How often do you have seizures and how long do they last?
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
Do you suffer from or have you ever suffered from heart issues such as high or low blood pressure, palpitations, or abnormal heartbeat? If so, please give details *
Do you have any fractures, tendon, ligament or cartilage damage or back problems? If so, please give details
Do you or have you suffered from migraines or headaches in the last 12 months? If so, please give details
Are you suffering from or are you a carrier of any infectious disease? If so, please give details
Are you currently suffering from severe stress or burnout? If so, please give details
Are you now or have you ever been on psychiatric medication? If so, please give details *
I currently or have had a history of alcohol abuse? If so, please give details
Do you have an eating disorder such as anorexia nervosa or bulimia? 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 *
Has a mental health professional ever recommended or advised that you do not take psychedelics? *
Have you ever been convicted of a crime? If so, please give details *
Have you been hospitalised in the last 2 years? 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. *
Have you been on juridical trial or in jail? If so, please give details
Have you experienced strong rage, anger or been violent in the past 3 years? 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? *
I am aware of, and have read, the risks associated with psilocybin which can be found on the Terms and Conditions section of the Inwardbound website ( https://inwardbound.nl/terms-and-conditions/ ). These include, but are not limited to, psychosis and HPPD (hallucinogen persisting perception disorder) *
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.

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

Small Group Retreat: 4 day 28th September- 1st October Netherlands

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