Retreat Application
Open Dates
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Welcome
Please fill out your details and press Continue.
First Name
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Legal name not necessary. Let us know what you'd like us to call you.
Last Name
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Email
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Cell Phone
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Send me a reminder if I don't register today
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Participant Info
Which retreat(s) are you interested in attending?
November 3rd-8th, 2024, Northern California
February 6th-9th, 2025, Northern California
March 16th-19th, 2025, Northern California
November 9th-14th, 2025 Northern California
Summer 2025, Colorado (Date TBD)
A private retreat with my own group
Who can we thank for sending you our way?
Internet search? Friend? Therapist? Past guest on a Same Summit retreat?
Please let me know about upcoming retreats, events and other offerings
Support Network
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Yes, I have a safe and supportive living environment to return to after the retreat
No, I do not have a safe and supportive living environment to return to after the retreat
We ask this question because your post-retreat environment plays an important role in feeling supported after such a powerful experience.
Are you currently supported by a coach or therapist?
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Yes, regular therapy
Yes, regular coaching, counseling or support group
Some type of counseling/therapy in the past but not currently
I've never received counseling or therapy
Medical: please check any of the following conditions that apply to you.
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Cardiovascular disease or surgery
Abnormal EKG reading
High blood pressure
High blood pressure (controlled with medication)
Low blood pressure
Fainting
Heart arrhythmia
Detached retina or glaucoma
History of brain aneurism
Epilepsy/Seizures
Diabetes, type I
Diabetes, type II
Thyroid conditions
Liver disease
Kidney disease
Currently pregnant or trying to become pregnant
Asthma or respiratory disease
Recent physical injuries
Recent/active communicable disease
None of these
Other Medical
Please list any other medical conditions, physical limitations or chronic illnesses that we didn't ask about. (If none, please write "none")
Have you recently, or are you currently, experiencing suicidal ideation?
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Yes
No
It's more complicated than yes/no
Psychiatric: Do you have any history of experiencing, or being diagnosed with, any of the following:
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Bipolar I
Bipolar II
Schizophrenia
Psychosis or a psychotic episode
Personality disorder
None of these
Select all that apply.
Family History: Does a member of your immediate family have a history of experiencing or being diagnosed with the following:
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Bipolar I
Bipolar II
Schizophrenia
Psychosis or a psychotic episode
Personality disorder
None of these
Antidepressant and Psychiatric Medications
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Please list any antidepressants or psychiatric medications you are currently taking/tapering off of (or write "none.")
Known or Suspected Trauma
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While psychedelic experiences can be very useful for healing from trauma, it is wise to first have a baseline understanding of past trauma before engaging with these medicines. Are you aware of any developmental (repeated over time, often during childhood) or acute (single unexpected/stressful event) trauma? If so, please provide a short summary below.
If this retreat had a profound effect, how might it positively impact your life?
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What kind of person might you become? What beliefs might shift? In other words, why do this retreat??
What's great about you?
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Humility aside, what are some of your gifts? (Cooking, asking good questions, playing an instrument, being a great father/mother, crunching numbers, organizing, dancing? Anything goes here!)
Prior Psychedelic Use
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Please describe your past history with psychedelics. (Which substances? Recreational? Ceremonial? None at all? Positive/challenging experiences?)
Have a question or anything else you'd like to share with us to help us get to know you better?
Nope, I think that's it
Yes I do! (Answer in next section)
Please share whatever you like here
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Begin Application
