Name & Email of both you and your partner:

How long have you and your partner been together?

Share a bit about where you're at currently

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

What’s your experience with MDMA?

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.

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

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

Please list any dietary restrictions.

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

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 acknowledge that my $1000 deposit is non-refundable.

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

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

Anything else you’d like us to know?