fbpx

Get In Touch With Us

To directly reserve your place on one of our signature psilocybin retreat programmes please fill the medical questionnaire below.

Alternatively contact us via the following form or book a free consultation if you have further questions.

Contact Us For A FREE Consultation

What’sApp
Book Now

Medical Questionnaire

Although in 95% of cases there are not contraindications when attending one of our retreats, for the safety and enhanced experience of our guests, we kindly ask all applicants to fill out a medical questionnaire. Please note that pre-existing conditions don’t automatically prevent participation. Yet, it’s essential for us to understand any factors that may contraindicate with the medical situations of our guests.

Please note: you have the option of speaking English, German, or Dutch. If you do wish to speak in either German or Dutch please respond to the questions below in your preferred language. However, keep in mind that our retreats are held primarily in English 

    My preferred language

    Gender

    On desktop computers, use the scrollwheel within the dropdown next to the month-year selection. On mobile devices, please tap on the year in the blue bar to easily select your year of birth.

    How did you hear about us?

    I want to sign up for

    Do you suffer from any physical health issues?

    Are you currently undergoing any medical treatments?

    Are you pregnant or do you breastfeed?

    Do you regularly drink alcohol or take drugs?

    Do you (on a regular basis) take any medications (both prescribed and non-prescribed)?

    Have you undergone any significant medical treatment or surgeries in the past 5 years?

    Do you suffer from any mental health issues?

    Have you or any member of your family suffered from any mental health conditions?

    Are you currently receiving therapy or attending any kind of support group?

    Do you have any experience with psychedelics?

    Have you experienced adverse or particularly difficult experiences with psychoactive substances that you have found hard to integrate?

    Is there anything not covered in the above questions you feel would be relevant for us to be aware of?

    I declare that I am willing not to consume any alcohol, drugs or medication for at least three days before attending the retreat (even up to two weeks in some cases), and that I am prepared to obtain consent from my doctor to take part in the session when this is requested from me by Rejuvyn:

    I declare that I have fully and truthfully completed this form.

    I hereby agree to the General Terms and Conditions*

    Sign up for our newsletter