If you have previously attended retreat with us, please login now to proceed to the event registration.Login Now Personal DetailsMedical HistoryFinish and Submit User Email * User Password * First Name * Birth Date * Phone Number * Last Name * Gender Please SelectMaleFemaleNon Binary Occupation * Have you taken Ayahuasca before? * Please SelectNoYes Have you experienced adverse or particularly difficult experiences with other psychoactive substances that you have found hard to integrate? * Please SelectNoYes Please share more details with us.... * 0/100 characters Do you have a past history of, or currently suffer from any serious health conditions? * Please SelectNoYes Please share your current and/or past health conditions * 0/100 characters Have you ever been hospitalized for medical reasons or had any surgeries? * Please SelectNoYes Please share more details * 0/100 characters Have you ever been hospitalized for psychiatric reasons? * Please SelectNoYes Please share more details with us... * 0 characters Do you have any history of depression, anxiety, psychosis, bipolar illness or ADHD? *Please note that ceremonies should not be seen as nor are they designed as a substitute for psychiatric or other medical care. * Please SelectNoYes Please share more details * 0/100 characters Are you currently taking any type of medications? * Please SelectNoYes Please list the medications (it is extremely important to be as honest and transparent with us) * 0/300 characters List any medications that you have taken in the past 12 months. Please include dosage and frequency taken. * 0/100 characters List any recreational substances that you have taken over the past 12 months. (Including alcohol and marijuana) * 0/100 characters Have you ever broken any bones? * Please SelectNoYes Please share more details... * 0 characters Do you have any heart conditions or blood pressure issues? * Please SelectNoYes Please share more details... * 0 characters Have you ever taken SSRI medication for depression? * Please SelectNoYes Please share more details... * 0 characters Do you have any gastric issues, or have you had gastric surgery? * Please SelectNoYes Please share more details... * 0 characters What is your purpose for attending ceremony? (100 words max) * 0/100 characters Do you have any Special Dietary Requirements/Food Allergies? * How did you hear about us? * Additional Information you would like the staff to know? (optional) 0/100 characters Accept and Submit *I certify that the questionnaire has been completed honestly and fully, and that nothing has been omitted. I understand the risks and benefits associated with participation in this ceremony Name PreviousNext Register & Pay Deposit Save and Continue Later
