Eligibility

Ayahuasca Retreat Health Questionnaire

Welcome to our Ayahuasca spiritual treatment centre! Your health and safety are our top priorities. Ayahuasca is a powerful plant medicine that can have profound effects on both the mind and body. In order to ensure that your experience with us is safe and beneficial, we kindly ask you to complete the following health questionnaire before your arrival. Please answer all questions honestly and to the best of your ability. If you have any concerns or questions, feel free to reach out to our staff for assistance.

Health Questionnaire

First name

Last name

Phone

Age

Emergency Contact Number

Have you ever been diagnosed with or experienced any of the following? - PTSD (Post-Traumatic Stress Disorder) - Panic attacks or severe anxiety- Bipolar disorder - Schizophrenia or other psychotic disorders - Personality disorders - Eating disorders - Suicidal thoughts or attempts - Other

How would you describe your current mental and emotional state? Are you currently experiencing any significant stressors or life challenges?

Have you ever participated in an Ayahuasca ceremony before? If yes, please describe your experiences:

What are your expectations for this retreat? What are your intentions for working with Ayahuasca?

Thank you! We’ll be in touch.

Recommendations:

While Ayahuasca can offer transformative experiences for many individuals, it may not be suitable for everyone. We recommend that individuals who fall into the following categories do not attend our retreat:- Individuals with a history of severe mental health disorders such as schizophrenia, bipolar disorder, or psychosis.

- Those who are currently experiencing acute psychological distress or unstable mental health conditions.- Individuals with a history of heart conditions, especially those on medications that may interact with Ayahuasca.- Pregnant or breastfeeding women.

- Individuals with a history of substance abuse or dependence who are not currently in stable recovery. If you have any concerns about whether the retreat is suitable for you based on your health history, please consult with your healthcare provider before attending.

Thank you for taking the time to complete this questionnaire. Your honesty and cooperation are greatly appreciated. We look forward to welcoming you to our Ayahuasca retreat center and supporting you on your journey towards healing and self-discovery.

Eligibility

Health Questionnaire

4X4 Jungle Drive

Dieta

Travel