Name

First Name

Last Name

Phone

Country

(###)

###

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Date of Birth

How did you hear about us?

Retreat Size

Single

Couple

Friends or Family (2-4 guests)

Group (5-10 guests)

Estimated Retreat Dates

Preferred Accommodation

Bali Villa with ocean view and private pool

Bali Villa with jungle view

Tiny Bali house

What do you want to get out of this retreat?

How would you describe your experience with plant medicine so far?

How would you describe your overall health? Do you have any medical conditions? Are you currently taking any prescription drugs?

Have you ever been diagnosed with schizophrenia or any mental health disorder?

Do you have any allergies or food restrictions?

Terms & Conditions

I confirm that I have read and agree to the Safety Guidelines.

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