Personal Questionnaire

In order to provide the best experience, we need to know more about you.

    First Name: *

    Last Name: *

    Age: *

    Current Medications (Including OTC and dosage info): *

    Psychiatric Medication History (Please list all antidepressants and/or mood stabilizers you have consumed in the past 6 months): *

    Medication Allergies: *

    Other Allergies (Bees, etc): *

    Have you consumed lithium in the past month? *

    Lithium can be extremely dangerous in combination with psychedelics. I agree to not consume lithium within 3 weeks of the retreat date. (Please type in your initials if you agree): *

    Do you have any difficulty with mobility? (stairs, etc.) *

    Dietary Restrictions (Allergies, intolerances): *

    Alcohol Consumption: (Eleusinia Retreat is generally an alcohol free zone. If you anticipate experiencing symptoms of alcohol withdrawal, please let us know and we can help you plan accordingly. We are not a detox facility.) *

    Would you like to have anti-nausea medication available for your use if needed? *

    Do you object to being offered anti-anxiety medication if the staff deems it appropriate? *

    Have you ever experienced visual disturbances or instances of psychosis? *

    Emergency Contact: *

    What would you say your main goals or focus areas are in attending this retreat? Tell us a little about your story.: