Name

First Name

Last Name

Phone *

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact's Phone *

Country

(###)

###

####

Gender *

Female

Male

Non-Binary

Other

Relationship Status *

Single

In a Relationship

Married

Divorced

Widow

Other

Do you snore? Or have you been told you snore? *

Yes

No

Name *

First Name

Last Name

Have you ever participated in a Plant Medicine Ceremony before? *

Yes

No

How many plant medicine ceremonies have you participated in? *

0-1

More than 5

More than 10

What type of plant medicine have you journeyed with? *

Ayahuasca

San Pedro (Huachuma)

Psilocybin

Peyote

Other

Have you ever participated in a Kambo ceremony? *

Yes

No

Name *

First Name

Last Name

Have you taken or are you currently taking any prescribed medication and/or over the counter medication (including homeopathics?)

Yes

No

Are you pregnant or currently doing IVF to try to get pregnant? *

Yes

No

N/A

Do you suffer from depression or depressive episodes? *

Yes

I've only ever experienced seasonal depression but have never taken anything for it

No

Have you taken or are you currently taking any kind of antidepressants? *

Yes

No

Have you taken or are you currently taking any natural supplements, herbal medicines, or vitamins? *

Yes

No

Do you agree to stop taking any antidepressants, prescribed medications, over the counter medications, herbal medications and vitamins, one month priorto joining this retreat? *

Yes

No

Have you had any surgeries? *

Yes

No

Are you suffering or have you ever suffered from any of the following health conditions? It is important to answer these honestly and correctly. *

Low Blood Pressure / Hypotension

High Blood Pressure / Hypertension

Hypothyroidism / Hyperthyroidism

Heart Condition / Heart Attack

HIV / AIDS

Obesity

Seizures / Epilepsy

Liver Disease

Pancreas Disease

Rheumatoid Arthritis

Viral Disease (Covid-19)

Gallbladder / Kidney Stones

Angina / Chest Pain

Chronic Pain

Tuberculosis

Gynecological Condition

Diabetes / Prediabetic

Autoimmune Disease

Physical Disability

Meningitis

Asthma

Aneurysm

Stroke

Neurological Disease

Infectious Disease

Migraine Attacks

Stomach Problems / Ulcers

Circulatory Problems

Cancer / Tumors / Chemotherapy

Cranial Trauma

Visual Impairment

Fibromyalgia

None of the above

Do you have any food allergies? All food will be prepared on site so we want to ensure to have options for everyone. *

Yes

No

Do you have any other allergies we need to know about that may be life threatening and require an Epipen to be onsite? (Insect bites/stings, medications, etc...) *

Yes

No

Please select any condition that you have experienced in the past or are experiencing now: *

Schizophrenia

ADHD / ADD

Psychosis / Psychotic Outbreak

Chronic Anxiety / Panic Attacks

Obsessive Compulsive Disorder (OCD)

Self- Harming

Hyperactive

Clinical Depression

Suicidal Tendency / Ideology

Bipolar Disorder

Autism / On the Spectrum

Depersonalization Disorder

Burnout

Despressive Personality

Paranoia

PTSD (Post Traumatic Stress Disorder)

Eating Disorder

Borderline Personality Disorder

Multiple Personality Disorder

Aggressive / Violent Personality

None of the Above

Have you ever experienced serious trauma (physical, emotional, mental, sexual, ect?) *

Yes

No

Do you drink alcohol? *

Yes

No

If so, how many drinks do you usually have per week? *

0-4

4-6

6 or more

Have you ever used any illegal or recreational drugs / street drugs, including cannabis? *

Yes

No

Have you ever been diagnosed or treated for any addiction? *

Yes

No