Psychedelic ACT retreat - Mindfulness Training

Apply to the ACT-informed psychedelic retreat programme

Thanks for your interest in our psychedelic ACT retreat programme! Please ensure that your answers are as comprehensive as possible.

First Name
Last Name
Your email address*
Retreat Dates
Postcode
Phone
please provide with country code
Picture
Max. file size: 64 MB.
Gender*
Date of Birth
MM slash DD slash YYYY
What are your mental health qualifications and experience?*
The more detail you provide in your answer, the better. We suggest you write at least 100 words.
What context or client population do you work with?*
The more detail you provide in your answer, the better. We suggest you write at least 100 words.
Please tell us about your own personal journey and development (ie challenges you might have faced, difficult (non-psychedelic) experiences, big shifts that have occurred. Also please include anything you are working on at the moment that this retreat could help with).*
The more detail you provide in your answer, the better. We suggest you write at least 100 words.
Tell us about your past and present use of psychoactive substances, especially psychedelics (but also including legal substances such as alcohol, nicotine, caffeine, and other substances that may not be legal in your jurisdiction: cocaine, ketamine etc)*
Tell us about any past or present mental health conditions (including depression, anxiety, psychosis and PTSD) or relevant life events*
Tell us about any history of psychosis, schizophrenia or bipolar disorder in your family*
Tell us about your physical health and any impairments*
Tell us about your experience with related practices (including meditation, breathwork, sound healing, dance, yoga, time spent in the wild and nondual contemplation)*
Are you using any medication? If yes, please provide the name, dosage, frequency of use, as well as details of the condition that is being treated.*
The food served at the retreats is vegan. Do you have further dietary requirements?*
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Research participation
- I am interested to participate in the single-case series design research project. Please send me full details.
"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 I undertake other activities (including yoga, meditation and breathwork) at my own risk also. I have provided a full and honest description of my physical and mental health, my family's mental health, and any medication that I am taking."
- Do you agree to the following statement?
"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 I undertake other activities (including yoga, meditation and breathwork) at my own risk also. I have provided a full and honest description of my physical and mental health, my family's mental health, and any medication that I am taking."
Emergency contact (name and telephone number)*
We recommend at least one person in your life is aware of your intention to participate in a psychedelic retreat and is able to offer support during the post-retreat integration period, if required. We will only contact this person in the case of emergency.
How did you hear about this retreat?
Total fee for ACT-informed Psychedelic retreat:
Price:
Please don't book flights until we have clearance regarding the coronavirus situation. Any payments made will be fully refundable in the event of a cancellation. It is fine to just fill out the application form without completing the payment on the following page. This way we can still assess your suitability and add you to any waiting list.

Privacy Statement

First of all, we’d like to thank you for taking the time to answer our questions. We ask for this level of detail so that we can give you the absolute best standard of care, both on the retreat and in the time leading up to it. As facilitators, we need to understand the kind of attention and environment a candidate will need to feel safe, supported and able to connect to themselves and the other participants. We also have a duty of care to all the other participants on the retreat, so we need to make sure that we are able to honour this by ensuring all candidates have a good degree of self-awareness. There is no pressure on the retreat itself to divulge personal information, though we do encourage sharing from the heart – you will be able to judge for yourself what you’d like to disclose. We take confidentiality seriously, so the information you provide to us will be kept confidential, and not shared with other participants on the retreats or anyone outside the retreats team. We may ask for input from one or more of the lead facilitators. The content of your retreat application will be stored in a database accessible only Mindfulness Training Ltd. Your data is held for the purpose of evaluating your suitability for the retreats programme and is not passed on to anyone outside of the organisation.

Terms and other information:

Training fee is non-refundable if cancellation is made less than 1 month before training starts.
A fee may be transferred to future training at no extra cost if we still have 12 active participants on the training.
Any balance on a deposit is due four weeks before the start of the course.
Our retreat (that can’t be run online) is refundable if there are travel bans from your country due to COVID.