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? * YesNo
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.) * YesNo
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.) * YesNo
Would you like to have anti-nausea medication available for your use if needed? * YesNo
Do you object to being offered anti-anxiety medication if the staff deems it appropriate? * YesNo
Have you ever experienced visual disturbances or instances of psychosis? * YesNo
Emergency Contact: *
What would you say your main goals or focus areas are in attending this retreat? Tell us a little about your story.: