Register

Name:

Address:

Postal Code:

Residence:

Mobile number:

E-mail address:

Date of birth:

Name and telephone number of contact person:

What do you do in everyday life?

Intention & experience

What is the main reason to participate in a truffle ceremony?

Can you write about any experience you have in the field of spirituality and personal development?

Do you have experience with psychedelics? If so, which and when:

Medical

Are you currently being treated by a doctor/psychologist/psychiatrist? If so, which treatment, for how long and for what?

Have you been treated by a doctor/psychologist/psychiatrist? If so, which treatment, how long ago, and for what?

Have you ever been admitted to a mental health clinic during the past 10 years? If so in what year, for how long and what was the diagnosis?

Are you currently taking any medications? If so, which ones, which dosage and for what?

Have you taken medication in the past? If so, which medication, how long ago and for what?

Do you have heart problems, high blood pressure, epilepsy, or another condition that I need to be aware of for your and my safety?

What can you tell about your physical health?

Are you currently pregnant or are you breastfeeding?

Please share something about your support system

Do you have previous or current experiences with addiction?

Do you use drugs such as Ecstasy, marijuana, cocaine, alcohol, or other types? If so, which ones and to what extent and frequency?

Personal statement

I am over 25 years old. I am fully responsible for my participation in this retreat. I choose to participate in these methods and to take on psilocybin. I'm not being forced into this by anyone.

I have truthfully informed the leadership of The Igniting Your Fire Within Retreat whether I am being treated. In that case, I discussed my participation in this psilocybin trip with my attending physician, psychologist or psychiatrist and provided the requested papers and information.

I have taken note of the risks associated with the use of psilocybin and I hereby declare that I have not taken any of the mentioned medication (I answer all items mentioned in Annex 1 with YES).

OR: I do take any of the medications as mentioned in Annex 1 SSRI/SNRI. Please state here your current use of which medication(s) and in what dosage:

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I declare that in the event of a change or start of medication after signing this statement, I will immediately inform Soul Perceptions. Failure to report changes and/or start of medication may result in cancellation of the retreat by Soul Perceptions.

I have taken note of the fact that one or more of the following reactions may occur while taking psilocybin: nausea, vomiting, diarrhea, intense emotions, body sensations and visions.

I share that with Stella what can help me in my process and what can help her in supporting me. I will take responsibility for my needs.

I have taken note of the fact that a psilocybin journey is meant to find deeper insights into myself.

I have taken note of the fact that my psilocybin journey is not a form of therapy or official treatment.

I follow the instructions of the supervisor and focus on my own process, breathing and sensations. I allow myself to (respectfully) express what is presented during the ceremony. Thus truthfully stated and signed,

Name:

Date:

Name and phone number of your contact person (partner, family member or friend) that I can call in case of a question or emergency:

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Annex 1 Contraindications

I hereby declare that: -

My blood pressure is within the normal range for my age (or can be controlled with medication).

I do not take any of the following medications:

o Monoamine oxidase inhibitors (MAOIs) like:

▪ Bifemelane (Alnert, Celeport)
▪ Caroxazone (Surodil, Timostenil)
▪ Isocarboxazid (Marplan)
▪ Metralindole (Inkazan)
▪ Moclobemide (Aurorix, Manerix)
▪ Phenelzine (Nardil)
▪ Pirlindole (Pirazidol)
▪ Selegiline (Eldepryl, Zelapar, Emsam)
▪ Tranylcypromine (Parnate)
▪ Toloxatone (Humoryl)

o Tricyclic antidepressants like:

▪ Amitriptyline
▪ Amoxapine
▪ Desipramine (Norpramin)
▪ Doxepin
▪ Imipramine (Tofranil)
▪ Nortriptyline (Pamelor)
▪ Protriptyline (Vivactil)
▪ Trimipramine (Surmontil)
▪ Lithium

I do not use any of the following medications, or have stated which one(s) and in what dosage:
o Selective serotonin reuptake inhibitors (SSRIs) like:
▪ Citalopram (Celexa)
▪ Escitalopram (Lexapro)
▪ Fluoxetine (Prozac)
▪ Paroxetine (Paxil, Pexeva)
▪ Sertraline (Zoloft)
▪ Vilazodone (Viibryd)
▪ Fluvoxamine

o Serotonin-Norepinephrine Reuptake
Inhibitors (SNRIs) like:

▪ Desvenlafaxine (Pristiq, Khedezla)
▪ Duloxetine (Cymbalta)
▪ Levomilnacipran (Fetzima)
▪ Milnacipran (Ixel, Savella)
▪ Venlafaxine (Effexor XR)

I do not use any of the following 'over-the-counter' substances or stop using them before the retreat:

o CBD oil (o) stop 7 days before the retreat)

o st. John's Wort (stop 7 days before the retreat)

o 5-HTP (stop 7 days before the retreat)

I, nor any related family member from the first and second categories, do not suffer from:

o schizophrenia
o psychotic disorders
o bipolar(I or II) disorder

Initial Participant:

Registration form

Igniting The Fire Within Psilocibyn Retreat

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