UNION Waiver

Please complete the following waiver.

Click the button below to start.


Question 1 of 15

Name & Email of both you and your partner:

Question 2 of 15

How long have you and your partner been together?

Question 3 of 15

Share a bit about where you're at currently

Question 4 of 15

What are you hoping to get out of this couples retreat?

Question 5 of 15

What’s your experience with MDMA?

Question 6 of 15

Are you on anti-depressants? MDMA and anti-depressants don’t mix well and can lead to Serotonin syndrome. If this is a yes for you, it unfortunately isn’t a fit and you will of course receive a full refund. The other option is to wean off of them for at least 6 weeks before the retreat. If this is a no, we completely understand.

Question 7 of 15

Have you ever been diagnosed with mental illness? Bipolar disorder, psychosis, schizophrenia, etc.? Please share more

Question 8 of 15

What would you want/need to feel safe in this container?

Question 9 of 15

Please list any dietary restrictions.

Question 10 of 15

A 60 minute massage by a professional therapist is included in this retreat, would you like one?





Question 11 of 15

A photographer will be at one or two days of this retreat to capture the experience.

These photos will be used for marketing purposes for upcoming retreats.


*Note: The medicine portion will not be documented. Couples practices, breathwork, yoga, and family meals etc will be.


I am okay with this.


I am not okay with this.

Question 12 of 15

I acknowledge that my $1000 deposit is non-refundable.





Question 13 of 15

I acknowledge that the remainder of my balance is due 3/1/2023 or I must forfeit my spot and my deposit.





Question 14 of 15

Is there any other medical information you’d like us to know? High blood pressure? Hypertension?

Question 15 of 15

Anything else you’d like us to know?

Confirm and Submit