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Blue Lotus Retreats: Application

Thank you for your interest in a private Blue Lotus retreat. Each retreat is fully private and tailored to you, so I review every application personally. Please answer as openly as you can. Everything you share is held in strict confidence.

About you

Full name

Email address

Phone number (including country code)

City and country you live in

Date of birth

Retreats are for adults aged 18 and over.

Occupation

How did you hear about Blue Lotus Retreats?

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Your intention

What is drawing you to a psychedelic-assisted therapy retreat at this point in your life?

What are you hoping will shift or change for you?

What have you already tried? (For example: talk therapy, somatic work, coaching, retreats, spiritual practice)

Why now?

Are you currently working with a therapist, psychologist or psychiatrist?

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B
C

If yes, are they aware you are applying for this retreat?

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B
C


Psychedelic experience

Have you had any prior experience with psychedelics or plant medicines?

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B

If yes, which ones? (Select all that apply)

If yes, in what setting?

Roughly how many times, and when was your most recent experience?

Have you ever had a difficult or challenging experience with a psychedelic? If so, please describe it and how you moved through it.

How did you integrate your past experiences? (For example: therapy, journalling, community, nothing in particular)


Health screening

This section is a first screen only. If your application progresses, you will complete a full health and psychological intake before anything is confirmed.

Are you currently taking any of the following? (Select all that apply)

Some medications interact with psychedelics. Please be thorough.

Please list all current medications and supplements

Have you, or has anyone in your immediate family, ever been diagnosed with schizophrenia, bipolar disorder or experienced psychosis?

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B
C
D

Do you have any heart conditions, high blood pressure, seizures or epilepsy, or liver conditions?

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B
C

If yes or unsure, please give details

Are you pregnant, breastfeeding or trying to conceive?

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C

Have you experienced thoughts of suicide or self-harm in the past 12 months?

I ask this so I can care for you safely. Answering yes does not automatically rule you out.
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C

Are you currently going through a major life crisis, recent loss or acute period of distress?

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B
C

How often do you drink alcohol?

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B
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E

How often do you use cannabis or other recreational substances?

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B
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Is there anything else about your physical or mental health I should know?


Your retreat

Where would you prefer your retreat to take place?

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If internationally, do you have a preferred country or region?

Preferred retreat length

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When in 2027 would you ideally like your retreat?

Do you have any accommodation preferences or requirements? (For example: privacy, nature, ocean, accessibility)

Do you have any dietary requirements or allergies?

Will you have a trusted person available to support you in the days after your retreat?

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B
C


Investment

Blue Lotus retreats are fully private, fully customised experiences, including preparation sessions, your retreat with Zena, accommodation and integration support. Are you in a position to invest in an experience at this level?

A
B
C

If accepted, how soon would you be ready to secure your place?

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D


Commitment

I understand a full health and psychological screening is required before my retreat is confirmed

I commit to attending all preparation and integration sessions

I confirm the information I have provided is true and complete

I consent to Zena contacting me about my application


Closing

Is there anything else you would like me to know?