Heaven On Earth Retreat Application Form

Name

Preferred Retreat Date

Date of Birth

Gender

Occupation

Phone

Where are you located?

How did you hear about us?

What do you hope to get from this retreat experience? What are some of your intentions, goals, expectations?

What is your level of surfing?

I don't plan on surfing, I'd rather swim and hang on the beach or at the resort

Never surfed in my life but want to try

Beginner

Intermediate

Experienced

Which boat excursion are you most interested in?

Snorkeling Day Trip

Shark Diving Open Water Day Trip

I'd rather skip the boat excursions and surf near the resort

Would you like to participate in Family Constellations Therapy prior to the retreat?

Yes, definitely!

Not sure, I need more information

No, I'm not interested

Please indicate your room preference. We will discuss this further on your application call.

SINGLE Occupancy - $5,250

DOUBLE Occupancy (2 Beds) - SOLD OUT

DOUBLE Occupancy (Single Shared Bed) - $3,650

QUAD Occupancy - $2,700

Are you registering with a partner or friend with whom you wish to share a room with? Please describe your ideal room situation:

Are you open to sharing a room with someone of a different gender?

Do you have any specific personal or professional problem you would like to address during this retreat?

Please describe your experience with spiritual practices including exploring Self, self-development, religious practices, meditation, yoga, breathwork, or any other contemplative practices.

What are your concerns, if any, about attending the retreat?

Have you used psychedelics before?

What is your general. level of comfort with altered states of consciousness? (1 = VERY UNCOMFORTABLE to 10 = VERY COMFORTABLE)

What is your general level of sensitivity to psychoactive substances? (This can include alcohol, caffeine, nicotine, RX medications, supplements, OTC drugs, cannabis, psychedelics,, etc.)

What is your level of sensitivity to sensory stimulus in general? (May include loud sounds, bright lights, strong smells, large crowds of people, other people's emotional states, etc.)

Very High Sensitivity

High Sensitivity

Moderate Sensitivity

Low Sensitivity

Very Low Sensitivity

I'm Not Sure / I Don't Know

Please describe your past and present use of psychoactive substances. (Includes substances like alcohol, cannabis, nicotine, psilocybin, ketamine, RX drugs, LSD, MDMD, etc.)

Please describe any experience with coaching, therapy or mental health counseling, past or present.

Do you have any dietary restrictions or food allergies?

Please describe any physical conditions that may limit your mobility or compromise your health. (Be sure to let us know if you have low blood pressure, low blood sugar, any inflammatory bowel diseases such as Crohn's disease or IBS, liver disease, or asthma.)

Are you currently taking any prescription medications or herbal supplements? If yes, please list them along with the name, dose, frequency, and condition being treated. (To ensure your safety with psilocybin, it is very important that you let us know about any and all medications & supplements you are taking.)

Please tell us about any past or present mental health conditions including depression, anxiety, bipolar disorder, PTSD, substance abuse, behavioral addictions, eating disorders or any other relevant life events.

Have you experienced significant grief or loss? Please let us know a little about what happened.

Do you or anyone in your family (first or second-degree relatives) have. schitzophrenia, bipolar disorder, or. any other psychiatric disorder?

The next few questions are for us to understand you better so we can give you the best care during your retreat experience. These questions are personal and are optional to respond if you do not feel comfortable sharing. These questions and this entire Application Form are 100% confidential.

Was your home environment abusive, unstable, or emotionally and/or physically hurtful during your first 18 years of life?

Did you feel neglected, or lack basic needs like clean clothes, food, and a sense of safety?

Did you live with anyone who was a problem drinker, used. street drugs, was frequently depressed, mentally ill, or went to prison?

Is there anything else you would like us to know when considering this application?

I certify that all information on this form is true, complete, and. accurate. I understand that acceptance to this retreat is partially based on the information provided in this form. I understand that the information provided on this form is truthful and accurate to ensure the safety of myself and the other retreat participants and staff, and that falsifying or misrepresenting this information could endanger myself or others. I understand that this retreat is not intended to be a substitute for medical or mental health treatment.

Form submission[]

WAVES OF AWAKENING 7-Day Surf, Psilocybin, & Soul Purpose Retreat July 2nd - 8th

3-Step Application Process:

Step 1:

Step 2:

Step 3:

Step 1:

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