Retreat Questionnaire - Lola L'Amour

First Name *

Last Name *

Email *

Phone Number *

Please include area/country code

Birthday *

Emergency Contact *

Please include full name, phone, email, relationship to you, and country of residence.

Intention

What is your overall intention for this retreat? *

(This can change, but it gives us an idea so we can begin to support your intention as soon as possible.)

What specific circumstances are you looking to shift through the work-play-magic we'll be doing? *

Do you have any dietary restrictions/preferences/allergies we need to know about? *

What's your hidden (or favorite) talent? *

If you were an animal, which one would you be? *

(There is no right or wrong answer!)

Why did you select that particular animal? *

What is it about this retreat that calls to you the most? *

What would you like to shift in the way you express your femininity?

If you're partnered, what do you hope to bring back to your relationship from this experience?

Ceremony Safety Questions

The following questions may be intense. It is not our intention to relive any traumas/pain you may have lingering or affecting you, but it helps us understand what healing modalities are safest for you. This is particularly important for participation in ceremonial plant medicine work, which sometimes has contra-indications we must consider for your safety.

We also ask these questions because you'll be working in a group during our retreat. We want to ensure a safe, healing space for all participants involved.

If you do not feel comfortable describing the associated medical detail, please write how you feel. If you'd prefer to only discuss it over the phone, then please note that in the details field.

Thank you so much for your honesty and understanding. ♥

Do you have any physical ailments or health challenges? (Please include all recent medications, herbal supplements, or health conditions) *

(Including, but not limited to: history of seizures, heart problems, blood pressure concerns, allergies, asthma, lack of mobility, chronic pain, migraines, etc.)

Have you ever had any suicidal thoughts or have you attempted suicide? *

Yes

No

Have you recently sought out any counseling, psychiatric, or energy work? *

Yes

No

Please describe that counseling/psychiatric/energy work experience *

Have you ever (past or present) suffered from addiction? *

Yes

No

What addictions? Have you initiated steps towards healing? *

(e.g. food/smoking/drugs/etc.)

Within the past 6-months, have you used any narcotics? *

Yes

No

Which narcotics have you used? *

Have you experienced other visionary medicines or psychedelics? *

Yes

No

Please share about your prior visionary medicine/psychedelic experience(s): *

How are you planning to participate in our ceremony with medicinal mushrooms? *

I wish to fully participate and ingest the medicine (dosage will be HIGHLY individualized)

I wish to hold space and connect energetically-only to the medicine

I plan to sit out of this circle

There is no wrong answer here, and you're free to update your plans for this as we go! This just helps us plan our ceremony supplies accordingly.

What else you would like us to know about yourself and your journey? *

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Ghost Ranch

Pre-Retreat Questionnaire

September 30th-October 5th, 2023

Intention

Ceremony Safety Questions

NAVIGATE

CONTACT

hello@lola-lamour.com

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