Intake - Anouk Bindels

What is your intention for participating in this Plant Spirit Retreat? *

What personal themes would you like to explore with us in this program? Please be generous in your answer. *

Thank you for your thorough research. Why did you choose to apply for a retreat with Anouk Bindels over others? *

Please share any previous experiences you have had with psychoactive substances, including frequency and dose. How did these experiences affect you, both short-term and in the long run? *

Have you suffered in the past from any physical health conditions, illnesses, or complications? What is the biggest challenge to your physical health today? *

Are you currently using any medication? If yes, please list them, including dosage and frequency. *

Please share some information about your current support network, including friends, family and professional support. Are you currently or have you in the past experienced professional therapeutic support? *

What is the biggest challenge to your emotional and mental health today? Please be specific. *

When you were a child, before the age of 10, did you experience any of the following?

Emotional or psychological abuse

Physical or emotional neglect

Divorce or separation of your parents

One or more parents was depressed or otherwise mentally ill

One or more parents was alcoholic or addicted to other substances

A parent or relative was incarcerated or in jail

None of the above

Please share some more information about this Childhood event, how it affected you at the time, and what impact it has on you today. *

Have you experienced a natural disaster, car accident, being in a war zone, or other kind of traumatic event in your life? When did this event occur and how has it affected you, then and now?

Have you ever been diagnosed or suffered any of these conditions / symptoms? Please mark which one.

Depression

Anxiety

Bipolar disorder

Personality disorder (please specify in the question below)

History of self-harm injury

Eating Disorder

Fibromyalgia

Suicidal attempts

Behavioral or substance addiction

Schizophrenia

Psychotic symptoms

Substance abuse

PTSD

Other (please specify in the question below)

None of the above

Repeated, disturbing, and unwanted memories of the stressful experience? *

Repeated, disturbing dreams of the stressful experience? *

Suddenly feeling or acting as if the stressful experience was actually happening again (as if you were actually back there, reliving it)? *

Feeling very upset when something reminded you of the stressful experience? *

Having strong physical reactions when something reminded you of the stressful experience (for example heart pounding, trouble breathing, sweating)? *

Avoiding memories, thoughts, or feelings related to the stressful experience? *

Avoiding external reminders of the stressful experience (for example people, places, conversations, activities, objects, or situations)? *

Trouble remembering important parts of the stressful experience? *

Having strong negative beliefs about yourself, other people, or the world (for example having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *

Blaming yourself or someone else for the stressful experience or what happened after it occurred? *

Having strong negative feelings such as fear, horror, anger, guilt, or shame? *

Loss of interest in activities that you used to enjoy? *

Feeling distant or cut off from other people? *

Trouble experiencing positive feelings (for example being unable to feel happiness or have loving feelings for people close to you)? *

Irritable behavior, angry outbursts, or acting aggressively? *

Taking too many risks or doing things that could cause you harm? *

Being “super alert” or watchful, or on guard? *

Feeling jumpy or easily startled? *

Having difficulty concentrating? *

Trouble falling or staying asleep? *

Do you have any first or second-degree relatives with schizophrenia, bipolar disorder, or any other psychotic disorder? If yes, please provide details. *

Do you have any experience with mind-body practices or holistic approaches? For example: Yoga, dance, mindfulness meditation, acupuncture, voice release, qigong, circling. *

How did you hear about Heart & Brain Plant Spirit Retreats? *

Would like to receive emails from us about future retreats? *

yes

no

Do you agree with the following statements? *

Wherein “I” refers to “You”, the participant of the Heart & Brain Plant Spirit retreat: “I am taking these psilocybin-containing truffles of my own volition. I acknowledge that no substance is entirely risk-free and that I am familiar and comfortable with the risks of psilocybin truffles. I understand that the retreat is not intended as a substitute for medical or psychotherapeutic care and agree that the Heart & Brain Plant Spirit retreat will not be held accountable for any issues that arise from my experience. I understand that I undertake other activities, including breathwork, dance, meditation, yoga, etc. at my own risk. I certify that all information provided on this form is true and complete. I understand that the admission to the retreat is based on some of the information provided on this form to ensure the safety of all participants and that any untruthful or inaccurate answers could lead to risks to myself or other participants. I accept the Terms and Conditions. (please check the box)

First name *

Last name *

Email *

Please provide us with a picture of yourself *

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Privacy *

Your data and our email exchanges are strictly confidential. They will only be kept within the Heart & Brain Training Organization to decide on how we can provide the best for you withing our retreats. Check the box if you agree to the storing and processing of your data.

In the past months, how much were you bothered by:

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right that best match your experience.