Participant Intake Form | Arah Retreats

Participant Medical & Intake Form

Please complete this confidential intake form thoughtfully and honestly. Your responses help us understand your needs, review your eligibility, and create the safest and most supportive retreat experience possible.

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First name

Last name

Phone

Birthday

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Year

Emergency Contact Name

Relationship to You

Emergency Contact Phone Number

Do you have any dietary restrictions, or special dietary needs? Please describe.

Have you previously participated in psychedelic or plant-medicine experiences? If yes, please describe what you have worked with and approximately when and how was your experience.

Please list any current medical conditions, diagnoses, or ongoing health concerns.

Have you had any surgeries, major injuries, or hospitalizations? Please describe and include approximate dates.

Please list all medications, supplements, or herbal remedies you are currently taking, including dosage if known. If none, please write “None.”

Do you have any allergies? If yes, please list them, including medication, food, or environmental allergies.

Have you ever been diagnosed with a heart condition, high or low blood pressure, seizures, epilepsy, diabetes, or another serious medical condition? Please explain.

Do you have any current or past mental health diagnoses? If yes, please describe.

Have you ever experienced psychosis, schizophrenia, bipolar disorder, mania, or been hospitalized for a mental health condition? Please explain.

Is there a history of schizophrenia, psychosis, bipolar disorder, or other serious mental health conditions in your immediate family? If yes, please explain. If none, write “None.”

Do you currently use alcohol, cannabis, recreational drugs, or other substances? Have you ever experienced problematic use, dependence, or addiction? If yes, please describe the substance, frequency of use, and when you last used it. If none, write “None.

How would you describe your current physical, mental, and emotional well-being? Please include any significant stress, grief, trauma, major life changes, or challenges you are currently experiencing.

Is there anything about your physical health, mental health, emotional well-being, medications, substance use, or personal circumstances that you have not already shared and that our team should know in order to support you safely? If none, write “None.”

What is your intention for this retreat? What are you hoping to explore, receive, heal, or reconnect with?

I confirm that the information I have provided in this form is complete and accurate to the best of my knowledge. I understand that withholding relevant medical, psychiatric, medication, or substance-use information may affect my eligibility to participate and my safety during the retreat.

I understand that submitting this form does not guarantee participation. My information will be reviewed to determine whether the retreat is appropriate for me, and I agree to provide additional medical information or medical clearance if requested.

I understand that retreat activities may involve intense physical, emotional, and psychological experiences. I have disclosed all relevant health information and agree to follow the safety instructions provided by the ARAH Retreats team. I understand that I may withdraw from any activity at any time.

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