MOTHERSHIP application — Path of the Rose

Retreat Application Form

Fill out the form below to apply for the Ayahuasca and Master Plant Retreat. We will respond to you via email with any questions and the next steps.

Your details

Name

First Name

Last Name

Which dates are you applying for

YYYY

Current location

Date of Birth

Occupation

Retreat Options

What option are you interested in

Retreat only

Retreat & Extra Mentoring

What draws you to this retreat?

Have you worked with us before if so in what way?

Health

Describe your current physical, emotional and mental health

List any medications you currently take

If none, leave blank.

Do you have a heart condition?

If yes, please explain.

Are you pregnant?

What is your existing spiritual practice if any?

Have you ever worked with visionary plants?

Such as ayahuasca, peyote, san pedro, psilocybin, OR taken psychedlics such as LSD, MDMA etc.

Do you have a history of sexual, physical or emotional trauma that you feel called to mention?

Please note this is all totally confidential.

Anything else you wish to add or ask?

Do you have an serious dietary requirements?

Emergency Contact

Do you agree to follow the safety protool and guidelines laid out in the info pack? And are you committed to following these through to completion?