Intake form – Coming Home

Please fill in with care

Intake form

This intake will be handled with strict confidentiality. Only the facilitators of the specific retreat or session will have access to it. If you would prefer to share certain information in a personal conversation instead, that is of course welcome.

Invullen in Nederlands of Engels / Fill out in Dutch or English

First name

Family name

Date of birth

Country of residence

Place of residence

Phone number

Emergency contact phone number

Email address

How did you find us?

What would you like to register for?

Individual retreat Group ceremony / retreat, specify date below

If group ceremony / retreat, please specify which date and/or plant medicine

Have you had experience with plant medicines or other psychedelics (Ayahuasca, San Pedro/peyote, magic mushrooms/truffles, bufo, LSD, …)? 

No Yes

If yes, which plant medicines/psychedelics, how long ago, and what were your experiences?

Can you share what motivates you to participate in this day ceremony, retreat, or individual session? Do you have a specific intention?

What are your experiences in the field of personal development? For example: therapy, courses/trainings, retreats, meditation/mindfulness, breathwork/bodywork, …

Select from the list below any conditions you currently have or have had in the past: 

High or low blood pressure Heart conditions, Epilepsy  Aneurysm  Diabetes  Chronic pain  Migraine  Cancer, please specify Stroke  Autoimmune disease (HIV/AIDS or other): Asthma  Stomach ulcer  Brain injury  Neurological disorder  Physical disability  Hyperthyroidism (overactive thyroid)  None of the above

Are there any other conditions you have or had? If yes, please specify

No Yes

If yes please specify

Select from the list below any psychological conditions you currently have or have had in the past: 

Psychotic episodes  Anxiety disorder / Panic attacks Dissociative identity disorder  Bipolar disorder  Borderline personality disorder  Depression  Self-harm  Post-traumatic stress disorder  Suicidal tendencies  Obsessive-compulsive disorder  Eating disorder  ADHD / ADD  Autism  None of the above 

Are there any other psychological conditions you have or had? If yes, please specify:

No Yes

If yes please specify

Do psychological disorders run in your family?

No Yes

If yes please specify

Are you currently in therapy?

No Yes

If yes please specify

Have you ever suffered from serious physical injury/trauma? 

No Yes

If yes, can you tell us more about it?

Are you aware of any form of sexual, psychological, or emotional abuse in your past?

No Yes

If yes, can you tell us more about it?

Are you currently, or in the past 2 months, taking antidepressants? 

No Yes

If yes, please specify which antidepressants and when you last used them:

Are you currently taking any other medication besides antidepressants? (Prescribed by a doctor or without prescription) 

No Yes

If yes, please specify which medication: 

Do you use natural supplements, medicinal herbs, or vitamins? (St. John’s Wort, 5-HTP, Kava, kratom, etc.)? 

No Yes

If yes, please specify which supplements:

Have you used drugs in the past months? 

No Yes

If yes, which drugs and how long ago?

Are you pregnant or breastfeeding? 

No Yes

As far as you know, can you share something about how your birth took place?

Have you experienced traumatic events in your life that have not yet been mentioned in this intake? This may also include the death of loved ones.

Are there any particular physical or emotional matters important for us to know, so that we can best support you during your journey?

Is there anything else you would like to add?

I hereby declare that I have answered all questions truthfully.

I accept the general terms and conditions of Coming Home.