6-Day Retreat Application

In order to process your application switfly, please take some time to answer our questions throughly. This application form helps us to provide the best care possible.

If you have questions before submitting you application, please book a free discovery call with a Kiyumí facilitator. Click here to book your free call.

Asunto *

Product

Name *

First Name

RequiredSurname

RequiredPronouns (e.g. he/him, she/her, they/them...)

Correo electrónico *

Date of Birth *

dd-MMM-yyyy

Country of birth *

( Country )

Country of residence *

(Country)

Teléfono *

Profession *

Are you interested in specific dates?

I am flexible

My dates are flexible?

Yes

Have you attended a Kiyumi retreat before? *

This would be my first time.

I have been a participant before.

I want to apply to the Kiyumi Equity Program

We aim to provide equitable access to safe psychedelic experiences to everyone through offering this scholarship. Please note: Spots for 2025 are open. Please note that we offer different types of scholarships, from 25%, up to 75% and 100% .

What is your intention for participating in this Kiyumi 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 Kiyumi 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? *

For example: Psilocybin mushrooms, LSD, ayahuasca, DMT, alcohol, ketamine, amphetamines, opioids, etc.

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

Please include any impairment that may limit your mobility, low blood pressure, low blood sugar, etc.

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

Please note: We can not accept applicants using antidepressant, mood-stabilising, antipsychotic or epilepsy medications. These may cause dangerous interactions or produce situations we are not equipped to manage safely in a group setting.

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 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? *

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

Your Hobbies/Passions *

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 Kiyumí Retreats?

Would like to receive emails from us about future retreats?

Upload a picture of yourself here

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Disclaimer

The Kiyumi programs are intended as an educational, experiential, and developmental offering. They are not suitable for persons seeking therapy or as a substitute for therapy and must not be attended in place of psychological or therapeutic support, especially for experiences such as psychosis, bipolar disorder, personality disorder, and schizophrenia.

If you are currently in therapy we recommend you to talk to your therapist about your intentions to participate in a psychedelic experience. It can also be useful to discuss your experiences and further explorations from the online program with your mental health professional for further insight.

To ensure the wellbeing of our participants we have chosen to adopt a set of comprehensive safety guidelines that preclude applicants currently using antidepressant, mood stabilising, and antipsychotic medications.

Kiyumí Retreat Participant Agreement

1. Personal Responsibility

I acknowledge that I am purchasing and taking psilocybin-containing truffles of my own volition. I am aware that no substance is entirely risk-free and have familiarized myself with the risks and contraindications. If necessary, I have consulted my general practitioner or mental health professional regarding these risks.

I have read, understood and accept the retreat consent form.

Participant Information: Liabilities, Retreat and Psilocybin Information, Cancellation

2. Nature of the Retreat

I understand that the Kiyumí retreat is an educational, experiential, and developmental offering. It is not a substitute for medical or psychotherapeutic care and is not suitable for individuals seeking therapy. I acknowledge that it is not recommended for those experiencing psychosis, bipolar disorder, personality disorders, or schizophrenia.

3. Assumption of Risk and Liability

I recognize that all activities of the retreat, including but not limited to psychedelic experiences, bodywork, breathwork, meditation, yoga, and group interactions, carry inherent risks. I assume full responsibility for my personal safety and any property I interact with. If I require medical attention during the retreat, I will cover any medical or legal costs incurred.

4. Code of Conduct and Duty of Care

I commit to attending the retreat for its full duration to maintain the integrity of the group experience. I agree to abide by the rules and agreements set by facilitators. I understand that failure to comply, including but not limited to posing harm to others, aggressive behavior, dishonesty, or unauthorized use of psychoactive substances, may result in my removal from the retreat. If my mental health condition is assessed as unsuitable for participation, Kiyumí reserves the right to withdraw my attendance. In such cases, suitability will be evaluated by the safety team, possibly through a separate consultation call.

5. Admission and Honesty

I certify that all information provided is true and complete. I agree to inform the Kiyumí team as soon as possible of any relevant changes, including new diagnoses, medications, or significant life events. I acknowledge that admission to the retreat is based on the information I provide to ensure the safety of all participants.

In the case of discontinuation due to previously withheld information about a participant’s medical or psychiatric history as well as spontaneous changes in condition, no refund will be issued.

6. Cancellation Policy

I have read and accept the terms and conditions in the retreat cancellation policies for Kiyumi Retreats. Your retreat fee includes a non-refundable €300 deposit. If you need to cancel, you can receive a 75% refund if you cancel 60 days before the retreat, 50% up to 30 days before, and 25% up to 14 days before. No refunds are available for cancellations within 14 days of the retreat. If you're paying in installments, the full payment is still required after the cancellation deadline. For assistance, contact us at contact@kiyumi.org.

7. Payments and Supplementary Products

I understand that retreat payments do not include the cost of psilocybin-containing truffles (€90 payment due upon arrival). I acknowledge that any supplementary products are not included in the fees and that Retreat Guru is not responsible for their provision.

I accept the Terms and Conditions.

Privacy Statement *

Yes I agree

Your data and our email exchanges are strictly confidential. They will only be kept within the Kiyumí Organization to decide on your suitability for our retreats. Choose yes if you agree to the storing and processing of your data.

Thank you very much, we will be shortly in touch and will forward you the last steps to secure your space in one of our upcoming Kiyumí retreats.

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