Name *

First Name

Last Name

Phone *

(###)

###

####

Have you tried posture therapy before? *

Yes, a lot

Yes, a little

Never

Have you tried psychedelics before? *

Yes, a lot

Yes, a little

Never

Which retreat packages interest you? *

Basic

VIP

Elite

Will you be able to abstain from all the substances listed below for 7 days before AND during the retreat? *

Coffee, green tea, caffeine, or other stimulants CBD, THC, Alcohol or other depressants RX: Antidepressants, Anti-Anxiety Medications, Tranquilizers, Benzodiazepines (Xanax), Lithium, Opioids, ADHD Medication, Pain Killers, Prescription Sleeping Medication (Melatonin is OK)

I will abstain

I might need help

Email permissions

I want to receive promotional material about future events and offers from Chronic Pain Mushroom Retreats. We respect your privacy. Your data will never be sold or shared, period.