Health, Preparation & Application

The JourneyHome

A path of healing, clarity, and transformation.

Thank you for your interest in joining The Journey Home experience. This application helps us understand your intentions, background, and needs, so we can ensure a safe, supportive, and transformative experience for all participants.

All information shared is strictly confidential and used only for participant care and retreat preparation.

Macro Ceremonies

Days Microdosing

Coaching Sessions

Sections · ~20 min

Section 1 of 7

Personal Information

Email *

Full Name *

Date of Birth *

Gender / Pronouns

Phone Number / WhatsApp *

Home Address *

Occupation

Section 2 of 7

Emergency Contact

Full Name *

Relationship *

Phone Number / WhatsApp *

Email Address *

Section 3 of 7

Health & Wellness

Do you have any current or past medical conditions we should know about? (physical, psychological, or neurological) *

Are you currently taking any prescription medications, supplements, or herbs? Please list all — include what it is taken for, how much (dose), how frequent, and for how long you have been taking it. * This is critical safety information. Certain medications are contraindicated with psilocybin.

Do you have any history of seizures, heart conditions, or other health concerns? If yes, please share complete details. *

Have you ever been diagnosed with depression, anxiety, PTSD, bipolar, schizophrenia, or any other mental health condition? If yes, please explain. Include timeline, duration, and intensity. *

Have you ever had thoughts of self-harm or suicide? If yes, please provide a summary of your experience. *

Do you have any allergies or dietary restrictions? If yes, please list all. *

How would you describe your current overall health? *

Section 4 of 7

Experience & Background

Have you participated in a retreat, ceremony, or similar experience before? If yes, please share briefly. *

What is your relationship or past experience with psychedelics, plant medicines, or breathwork (if any)? *

If you are interested in attending a group retreat, how do you typically respond to group settings and vulnerable environments? *

Section 5 of 7

Intentions

What draws you to The Journey Home experience at this time in your life? *

What would you like to receive, release, or gain from this experience? *

Is there a specific challenge, transition, or healing journey you are navigating right now? *

Do you have a spiritual or mindfulness practice (meditation, journaling, prayer, etc.)? If yes, please describe. *

Section 6 of 7

Practical Details

Do you have any accessibility needs we should know about? *

Are you comfortable with periods of silence, digital disconnection, and group sharing? *

Group Retreat Participants Only — Room preference:

Shared Room Private Room Shared Bed with partner / friend Not applicable — Private Retreat

Dates: *

Upcoming Group Retreat Private Retreat — specify date preferences below Other

Date preferences or additional notes on timing

Section 7 of 7

Agreements

Please check each box to indicate your agreement.

I understand that this retreat is not a substitute for medical or psychiatric care.Required

I agree to disclose my health information honestly for my safety and the group's wellbeing.Required

I will respect the privacy, boundaries, and experiences of all participants.Required — check if attending group retreat, or N/A for private

I understand participation is at the discretion of the facilitators.Required

Enter your full name as digital signature of agreement *

Date of completion of this application *

All information provided is strictly confidential and used solely for participant care and retreat preparation. We will be in touch within 48 hours of receiving your application.

Jacqui will review your application personally and be in touch within 48 hours.
In the meantime, feel free to book a discovery call if you'd like to connect sooner.