Thank You Life

Retreat Center Application

Your Name *

Your Email *

Business Name *

Mailing Address *

Website *

Your Role *

Business Information

Are you located in the U.S. or international? *

U.S.

International

Retreat location *

Federal Tax Identification Number (U.S. based only)

Person or entity to whom the identification number belongs

Liability insurance provider & coverage *

Liability insurance policy number *

Legal

Have you or any of your facilitators ever been found guilty of unprofessional, illegal or unethical conduct in a criminal or administrative or judicial proceeding? *

Yes

Have you had a professional license or certification denied, probated, suspended, or revoked? *

Yes

Have you ever surrendered any license or certification? *

Yes

Have you or any of your facilitators ever been found liable of unprofessional or unethical conduct in a civil lawsuit or proceeding? *

Yes

Are claims or charges pending against you for any of the above? *

Yes

If you answered YES to any of the preceding questions, you must attach an explanatory statement.

Upload file(s)

Service Information

Which medicine do you work with? *

Ayahuasca
Psilocybin
Iboga/Ibogaine
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Which lineage or tradition do your healers and facilitators work in? *

When did your center open? *

Please describe your intake screening process (e.g. physical and mental health clearance). *

Does each guest have 24/7 access to psychospiritual support while on the premises? *

Yes

How does a guest access support in the event of a psychospiritual emergency? *

What is the typical cost of a retreat? (this can be a range) *

Please outline a typical retreat (e.g. screening, intake, prep, number of ceremonies, in-house integration sessions, yoga/breathwork/meditation, post-retreat information sessions, etc.) *

Thank You Life collects 3 quantitative assessments from grant recipients in order to demonstrate the efficacy of medicine work for mental health conditions (depression, anxiety, PTSD). Please check "I Agree" to allow us to collect these assessments from grant recipients going to your center. *

I Agree

Do you focus on serving any particular high-need priority populations or communities?

Anything else you'd like us to know?

Why is improving access to plant medicine important to you? *

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