Retreat - MindLift

Email address*

Name*

First Name Last Name

Phone Number*

What is your intention for joining this retreat?*

Have you ever done a Plant Medicine Ceremony before? If yes, please mention which medicines you've worked with and specify briefly*

Waiver of Responsibility

A plant medicine ceremony like the one we will be doing comes with risks. It could bring up feelings of fear, anger, frustration, confusion or other negative psychological effects, and in exceptional cases can lead to psychosis or schizophrenia. The use of these substances (and therefore joining this ceremony) is in all cases entirely at your own risk. The ceremony organizer, ceremony holder, affiliated partners and companies can in no way be held liable for the consequences of joining this ceremony.

Contra Indications

The ceremony should not be joined in the following cases (participant has the right to request a refund):

Pregnancy or breastfeeding
history of schizophrenia or other psychological disorders
addiction (such as alcohol), an addiction history
currently under treatment by a doctor or psychologist
use of medication
Inability to look at oneself or take responsibility.

Answer the following questions

If you have to answer "no" to any of these questions, please contact us first.

I am aware of the risks involved in attending this ceremony and of the contraindications.*

Yes

I declare that I am in good health and currently not on any (prescription) medication.*

Yes

I declare that I am not currently being treated by a physician, psychiatrist, or psychologist, or have been treated for addiction, schizophrenia, or other psychological disorders.*

Yes

I declare that I am not pregnant or breastfeeding at this time.*

Yes

I declare that I am well able to look at myself, to take responsibility for my own choices, interpretations and (mental) process.*

Yes

I declare that I will never hold the ceremony organizer, ceremony holder, affiliated partners and companies liable for both the anticipated and unforeseen risks or consequences of attending this ceremony.*

Yes

I understand that this statement is binding as a contract, is not for informational purposes only, and I declare that I have signed this document of my own free will.*

Yes

Medicine Retreat Intake Form

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