Application

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* These fields are required

1 Welcome

2 People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

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3 Personal Information

Name you prefer to be called
Email newsletter	Please subscribe me to your email newsletter!
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Phone Number *
Can we leave voicemails on this number? *	Yes No
Birth Date *
Gender *

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4 Emergency Contact

Emergency Contact Name *	Excluding anyone attending the retreat with you.
Emergency Contact Relationship *
Emergency Contact Phone *
Emergency Contact Email *

5 Reasons for Attending MycoMeditations

What challenges in your life would you be joining the retreat to work through? *
Describe your intentions and goals for the retreat *

6 Mental Health Information

Mental Health History (Please select a box only if you have been diagnosed by a medical professional. Do not self-diagnose) *	Generalized Anxiety Social Anxiety Panic Attacks Clinical Depression Bipolar 1 Bipolar 2 Schizophrenia Psychosis Psychotic Episodes Paranoia Personality Disorders Attempted Suicide Suicidal Ideation Self Harming Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Attention Deficit Hyperactivity Disorder (ADHD) Autism Body Dysmorphia Anorexia or Bulimia Gender Dysphoria Depersonalization or Dissociation Alcoholism or Other Drug Addictions None
Describe the nature of your last psychotic episode *
When was your last psychotic episode? *
What brought on your last psychotic episode? *
Which personality disorder have you been diagnosed with? *
Describe how your personality disorder presents itself in your daily life? *
When did you last attempt suicide? *
How many times have you attempted suicide? *
Do you ever think of attempting suicide again? *
How often do you currently have suicidal ideation? *
Would you ever act on suicidal ideation? *
What is the nature of your self-harming? Include frequency and most recent episode. *
Describe the nature of your depersonalization or dissociation *
How often do you have an episode of depersonalization or dissociation? *
What substances are or were the focus of your addiction? *
Describe the nature of your addiction to the various substances that you currently have or previously had issues with *	Quantity consumed, consequences of use, etc.
When was the last time you used the substance of your addiction? Include frequency of use. *
Do you currently have addictions or cravings towards alcohol or other drugs? *
Do you agree to abstain from all alcohol and drug use if you attend MycoMeditations (except psilocybin) *
Do you agree to engage in any required detox with the help of a medical professional in order to attend MycoMeditations? *
Do you suspect that you may be suffering from any of the conditions listed above? *	Enter "no" if there are no additional suspected mental health conditions.
Other Mental Health Diagnoses *	Enter "none" if there are no additional diagnoses.
Mental Health Details *	Please provide very specific details for each condition that you checked. Include diagnosis history, types of treatments undertaken to date, the duration and effectiveness of treatment and whether you are still participating in the various treatments. Failure to provide these details may result in delay or denial of your application. Enter "none" if none of the above have been checked.
Have you ever received therapy or other psychological services? *
Explain More *	Please share other details in regards to the therapy you have received, such as the issues or conditions you went to therapy for, duration of therapy received, if you are currently seeing a therapist, number of therapists, and effectiveness. Please include services with psychologists and psychiatrists as well.
Please describe your recent mental and emotional state *
Please describe any trauma(s) or abuse that you have experienced in your lifetime *	Enter "none" if you feel you haven't experienced trauma or abuse. Enter "unsure" if you can't remember your history of trauma or abuse clearly.
Current Mental Health Medications *	Please list any current psychiatric medications including dosage and time on medications. Enter "none" if you are not currently taking any psychiatric medications.
Past Mental Health Medications *	Please list any past psychiatric medications including dosage and time on medications. Enter "none" if you haven't taken any psychiatric medications in the past that you aren't currently on.
Would you be willing to taper off of all psychiatric medications with the guidance of a licensed medical professional before attending your MycoMeditations retreat? *
Psychiatric Hospitalizations *	Please provide details about any psychiatric hospitalizations you have had. Include the nature of the hospitalization and the date. Enter "none" if you have never been hospitalized due to any psychiatric/mental health concerns.
Substance Abuse Rehabilitations *	Please provide details about any substance abuse rehabilitation you have had. Include the nature of the rehabilitation and the date. Enter "none" if you have never been in a rehabilitation facility due to substance addiction/abuse.

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7 Self-Assessment: How often do you experience the following?

Angry Outbursts *
Extreme Mood Swings *
Impulsivity *
Fears of Abandonment *
Emptiness *
Lack of Identity *
Lack of Empathy *
Grandiosity *
For those you have selected as Rarely, Sometimes, Often, or Always, please describe in detail the ways in which the symptom presents itself in your life. *	Please include information such as how frequently you feel that way, what triggers these feelings, how you respond to them, and how they affect your relationships. Enter "N/A" if you only selected Never for the above symptoms.

8 Family Mental Health Information

Family Mental Health History (Please check only diagnoses for blood relations) *	Generalized Anxiety Social Anxiety Panic Attacks Clinical Depression Bipolar 1 Bipolar 2 Schizophrenia Psychosis Psychotic Episodes Paranoia Personality Disorders Attempted Suicide Suicidal Ideation Self Harming Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Attention Deficit Hyperactivity Disorder (ADHD) Autism Anorexia or Bulemia Depersonalization or Dissociation Alcoholism or Other Drug Addictions Other None
Who in your family had Bipolar 1 disorder? *	Please include only blood relatives.
Who in your family had Bipolar 2 disorder? *	Please include only blood relatives.
Who in your family had schizophrenia? *	Please include only blood relatives.
Who in your family had psychosis? *	Please include only blood relatives.
Who in your family had psychotic episodes? *	Please include only blood relatives.
Who in your family had paranoia? *	Please include only blood relatives.
Who in your family had a personality disorder? *	Please include only blood relatives.
Which personality disorder did the family member(s) have? *
Family Mental Health History Details *	Please provide details such as who in your family suffered from the above conditions if you check any condition. Please elaborate on your family member's condition if you selected "Other". Enter "none" if none of the above have been checked.

9 Cardiovascular Health Information

Cardiovascular Health	High Blood Pressure Circulatory Problems Irregular Heartbeat Past Stroke(s) Past Heart Attack(s) Past Aneurysm(s)
What is your typical blood pressure reading? *
How many strokes have you had? *
When did your stroke(s) occur? *
How many heart attacks have you had? *
When did your heart attack(s) occur? *
When did you last have an aneurysm? *
How many aneurysms have you had? *
Have you ever had surgery related to a heart condition? *
What was the procedure(s)? *
When was the procedure(s) completed? *
Cardiovascular Medications *	Please list any current medications including dosage and time on medications. Enter "none" if you are not currently taking any medications.
Past Cardiovascular Medications *	Please include when you took them and how long you were on them. Enter "none" if you haven't taken any cardiovascular medications in the past.

10 General Health Information

General Health *	Traumatic Brain Injury Concussion(s) Fainting Chronic Pain Diabetes Obesity Insomnia Sleep Apnea Irritable Bowel Syndrome Epilepsy or Seizures Thyroid Conditions Autoimmune Disorder Cancer Infectious Disease Other None For any item checked, please provide specific details in the Physical Health Details box below.
Are you currently pregnant? *
When did the TBI occur? *
How did the TBI occur? *
Describe Other General Health Conditions (if you checked "Other") *	Enter "none" if none of the above have been checked.
General Health Details *	Please provide very specific details for each condition you checked. Include diagnosis history, month/year of hospitalizations or surgeries, current readings/test results (such as typical blood pressure or heart rate), whether the condition is being controlled with medication and/or lifestyle changes as well as the duration and effectiveness of these changes. Failure to provide supporting details may require in delay or denial of your application. Enter "none" if none of the above have been checked.
General Health Medications *	Please list any current medications including dosage and time on medications for the above conditions. Enter "none" if you are not currently taking any medications.
Please list any other medications you have taken in the past *	Please include when you took them and how long you were on them. Enter "none" if you haven't taken any medications in the past for the above conditions that you aren't currently on.
Past Injuries or Active Disabilities	Please provide details of any past injuries or active disabilities.

11 Other Medications, Supplements, and Allergies

Please list any other medications not listed above that you are currently taking including dosage and time on medications *	Enter "none" if you aren't currently taking any medications.
Please list any vitamins or supplements you are currently taking *	Enter "none" if you aren't currently taking any vitamins or supplements.
Please list any recreational drugs you currently use *	Enter "none" if you do not currently use any recreational drugs.
Please list your allergies *
Do you have any severe or potentially life-threatening allergies that would require the use of an EpiPen? *	If you answered "yes" to this question, please be sure to bring an EpiPen with you, as they are very difficult to obtain in Treasure Beach, Jamaica.

12 Other Details

Which retreat location are you interested in? *	Blue Marlin Rainbow Tree Bluefields Bay Private Retreat You may check multiple boxes.
Please enter the date that your passport expires *	Enter "1" for the day if your passport expires as MM/YYYY.
If your passport is expired, please enter you plans for renewal
Valid Passport *	By checking this box, I understand that I need a current passport to travel to Jamaica, that is valid for my dates of stay.
Please list any mobility limitations or special accommodation needs	For example, limitations in using stairs, walking on uneven surfaces or beyond certain distances, mobility aids that you use (such as a cane, walker or wheelchair), whether you need a walk-in shower, and similar items.

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13 Previous Psychedelic Experience

Have you attended a MycoMeditations retreat before? *
What were the results?
Have you ever done psychedelics? *
How many times?
What were the results?
Who have you done them with?

14 Referral

How did you first find out about MycoMeditations? *
Please elaborate further if possible (ie: which podcast, which article, which therapist referred you, which family/friend referred you, etc.) *
If applicable, please enter the first and last name of the person who referred you to MycoMeditations:	Note that in order for you to receive their referral discount you must enter their full name here. (MycoMeditations will not accept postdated requests for referral credit under any circumstances.)

15 Terms, Conditions and Attestations

Health Screening and Full Disclosure *	Check this box if you have read and understand the Health Screening and Full DisclosureBy checking this box and typing my name in the field below, I acknowledge that MycoMeditations will rely on the information provided in this application to screen for risk factors that may preclude me from attending a retreat, as a matter of my own safety. I hereby attest that the information provided is true and complete, to the best of my knowledge. All information I have provided in the application is correct and current and I have disclosed all physical and psychological conditions as well as all supplements, natural medicines and medications (prescription and over-the-counter) that I am taking. I also agree to promptly notify MycoMeditations of any new diagnoses or changes to the application information provided that may occur between now and when I attend retreat. I understand that my attendance at the retreat for which I am applying and/or access to psilocybin mushrooms may be denied at the sole discretion of MycoMeditations, if (1) it is determined that relevant information has been falsified or omitted on my application or (2) I exhibit dangerous behavior or seem too unstable for psilocybin at any point during the process. I also understand that I am not entitled to a refund in either of these circumstances. Note and disclaimer: In some cases, you will be contacted personally by one of our staff to ensure that you are prepared for the experience. MycoMeditations is not a medical facility and its owners, staff, employees and agents are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat disease or illnesses. Instead, we function as guides and facilitate the effects that psilocybin mushrooms have on people.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Acting on Own Behalf *	Check this box if you have read and understand the requirement to Act on your Own BehalfBy checking this box and typing my name in the field below, I attest that I am submitting this application on my own behalf, that all information included is in regards to my own personal information, and that I am not submitting this application on behalf of anybody else.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Psychiatric Medications Notices *	Check this box if you have read and understand the Psychiatric Medications NoticesBy checking this box and typing my name in the field below, I understand that: 1. If I choose to attend a MycoMeditations retreat without tapering off my medications that there is a significant chance that my experience with psilocybin mushrooms will be reduced. 2. I should not make any changes to my use of prescribed psychiatric medications until I have consulted with a licensed medical professional. 3. If there are any changes to my medications between now and when I attend my retreat, I must promptly notify MycoMeditations.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Medical Consultation for Prescription Medications *	Check this box if you have read and understand the Medical Consultation for Prescription MedicationsBy checking this box and typing my name in the filed below, I acknowledge that MycoMeditations representatives are not licensed to give advice on prescription medications and I agree to consult my doctor before discontinuing the use of any medications. If my doctor approves discontinuing my medications, I agree to follow the weaning process provided to me by my doctor.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Agreement to Read All Communications *	Check this box if you Agree to Read All CommunicationsBy checking this box and typing my name in the field below, I agree to read all emails, messages and attachments that are sent to me by MycoMeditations from the time of my application up to the retreat date. I understand that these communications will contain important information and instructions regarding my scheduled retreat, and some communications will require me to take actions that are pre-requisites for travel and/or for attending the retreat. If I fail to do so, and I miss an important requirement, I understand that I will not be refunded or allowed to transfer to a future retreat.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection * *
Informed Consent *	Check this box to confirm that you will be required to sign an Informed ConsentBy checking this box and typing my name in the field below, I understand that if my application is approved, I will be required to sign an informed consent in order to be able to attend a retreat at MycoMeditations. The Informed Consent is a document that provides information to you that we feel is important for you to consider in deciding whether to participate in the retreat, such as possible side effects, risks and benefits of consuming psilocybin mushrooms. By signing the Informed Consent, you are acknowledging your receipt and understanding of this information. You will be given the opportunity to ask questions and obtain clarification for anything within the Informed Consent that you deem necessary.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Accident and General Release of Liability Agreement *	Check this box if you have read and agree to Accident Waiver and General Release of Liability AgreementIn consideration of my application and permitting me to participate in this activity, the sufficiency of which is hereby acknowledged, I hereby take action for myself, and attest that such actions are binding upon, my executors, administrators, personal representatives, heirs, next of kin, successors, and assigns as follows: (A) I waive, release, and forever discharge from any and all liability, including but not limited to, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, the following entities or persons, hereinafter collectively referred to as “Releasees”: MycoMeditations Limited, JamTravel Enterprises, Inc., Magnificent Mushrooms Limited, accommodation facilities (including but not limited to Doranja House, Blue Marlin & Coquina Villas, Bluefields Bay Villas, Rainbow Tree Villas), Treasure Tours, Wise Wellness and/or their directors, officers, employees, independent contractors, vendors, volunteers, representatives, and agents, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named. (B) I indemnify, hold harmless, and promise not to sue the Releasees, individually or collectively, for any and all liabilities or claims made as a result of participation in this activity. (C) I acknowledge that Releasees are not responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. (D) I acknowledge that this activity may involve a test of a person’s physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, facilitators, and/or producers of the activity. These risks are not only inherent to participants, but are also present for employees, independent contractors and volunteers. (E) I hereby assume all of the risks of participating in any/all activities associated with this event I certify that I have sufficiently prepared or trained for participation in this activity, and have not been advised against participating by any qualified medical professional. I certify that there are no mental or physical health-related reasons or problems which preclude my participation in this activity. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. I acknowledge that this Accident Waiver and General Release of Liability Agreement will be relied upon by the Releasees and that it will govern my actions and responsibilities at the retreat. The Accident Waiver and General Release of Liability Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I certify that I have read this document and I fully understand its content. I am aware that this is a release of liability and a contract and I agree to it of my own free will. By checking this box and typing my name in the field below, I hereby waive, release and hold harmless Releasees from any and all liability or responsibility for all injuries and/or damages or claims which may occur in the event I do attend the retreat.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Confidentiality Agreement *	Check this box if you have read and understand the Confidentiality AgreementBy checking this box and typing my name in the field below, I recognize and agree that any and all information shared with me as part of my participation in this retreat is confidential and/or proprietary, and this confidential and/or proprietary information shall not be divulged to any third party, such as the media, unauthorized individuals, agencies or organizations. This information includes, but is not limited to, medical and mental health information about other retreat participants, and trade-secrets, know-how, standard operating procedures and protocols of MycoMeditations. If I am a journalist or other member of the media, I agree and understand that my attendance at a retreat is solely for personal healing and growth purposes, and the details cannot be used for any publication, article, documentary or media purposes. All media inquiries should be directed to the CEO for a separate and distinct discussion outside of the scope of this Agreement .
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *
Media Release Agreement: *	I grant permission I do not grant permission Occasionally MycoMeditations seeks to record still images, audio and video testimonials, interviews and accounts. These are intended for use within podcasts, website, YouTube and various other outlets in order to help normalize wellness through psilocybin. With this release, you are either granting or denying permission to use your image, voice or testimonials for these purposes. Client confidentiality is of the utmost importance to MycoMeditations and we will never post or use your image, voice or statements without explicit permission. By granting permission and writing my name in capital letters, I am authorizing MycoMeditations to use my likeness, recordings of audio and video, interviews and statements for editing and publication on proprietary websites, podcasts, educational and marketing materials in a diverse setting with unrestricted geographical presence. I waive the right to royalties or other forms of compensation for using my image, voice or likeness. By granting permission and writing my name in capital letters, I acknowledge that I have read this completely and agree with the contents. By granting permission and writing my name in capital letters, I release all claims upon MycoMeditations and their affiliates in the utilization of this material.
Please type your name in CAPITAL letters to show that you understand the above and confirm your selection *

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