Every journey with the medicine is unique, what is the call from your heart for coming to Medicine at this time? What areas of your life are you calling in healing for at this time? (health, clarity on your life path, deepening of your spiritual practices, relationships, career, etc.) Please explain in detail why you want to participate in an Ayahuasca ceremony. *

Will this be your first time participating in an Ayahuasca Ceremony with the Shipibo Healers? If not, how were your previous experiences *

Please give an estimate of how many Ayahuasca ceremonies you have attended in the past. *

What wellness and/or spiritual practices do you regularly engage in? (yoga, meditation, tai-chi, psychotherapy, music, art, exercise, gardening, journaling, a particular spiritual philosophy, etc *

How would you describe your phycological health and general mental-health wellbeing? *

Please give details of your physical health history, reporting all serious diagnosed conditions and procedures, including any major surgeries, and any undiagnosed issues you feel are relevant. Also please share your physical fitness level as Hikes in the Jungle are part of this package *

Please share if you identify with any of the following Diagnosis

High Blood Pressure

Heart Surgery/Heart Attack (date)

Psychosis

Bi Polar Disorder

Dissociative Identity Disorder (Formerly known as Multiple Personality Disorder)

Schizophrenia

Suicidal Ideation (thoughts about suicide or attempts at suicde)

Psychotic Paranoia

Anxiety Disorder (panic attacks, OCD, etc)

Eating Disorder

PTSD

Self Harm

Further Information - including how long you have been experiencing any symptoms so that the Maestros can develop a treatment plan

Please list all current medications and supplements you are taking (Prescription, over the counter, natural, vitamins etc.). Please also share any medications you have used long term, such as anti depressants, anti-anxiety medications etc and the time period you used them for and date you stopped taking them. *

Please give details of any substances you are currently using, or have used in the past. Have you ever experienced substance abuse issues or addictions? (Including Alcohol, Cannibis, Cocaine, MDMA, Herion, or to prescription medications). *

Please list any dietary requirements you have. Do you have any severe allergies to foods? *

Will you be attending the retreat with anyone you know? Please provide names and your relationships. *

Do you speak any of these languages? *

English

Spanish

Shipibo

Other

How did you hear about us? *

Referral

Website

Forum

Social Media

Other

Additional Comments - please share referral name, forum, platform or specify other *

Emergency Contact Name, phone number and email *

Passport Number (required if flying to centre) *

Agreements

I will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing

I will discontinue all use of alcohol, marijuana, recreational, street drugs and nonprescribed pharmaceuticals at least 3 weeks prior to commencing the retreat. I understand that many street and recreational drugs are strongly contraindicated with medicines like Ayahuasca and can be very dangerous and potentially fatal when combined

I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications.

Thank you!