Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Selected Ceremony Date
*
MM
DD
YYYY
Are you currently under the care of a healthcare professional
*
If yes, please list the name, contact information, and reason for treatment
Please list any prescribed medications you are currently taking, or have in the past 60 days
*
Please list all non-prescription medications you take
*
Please list any supplements you currently take
*
Please describe your current use if applicable to caffeine, tobacco, alcohol, cannabis, and recreational drugs
*
Please tick the boxes which indicate conditions you have had or presently have. If any other conditions, please list them on the box down below:
*
Other known conditions
Do you have any known allergies? If so list below
*
Explain if you suffer from any mental illness (depression, bi polar, schizophrenia, obsessive compulsive disorder, paranoia, psychosis, suicidal tendencies, multiple personality disorder, chronic anxiety, PTSD, clinical depression, borderline personality disorder, chronic anxiety, self harming, etc.)?
*
Are you currently taking ANY anti depressant medications OR supplements currently prescribed or self administered and the duration you have been taking them (including phenibut, psilocybin, cannabis, ketamine, etc)? Please list the dosage and length of time you have been taking them.
*
Have you ever attempted suicide, had suicidal thoughts or self harm?
*
Have you ever had a spiritually transformative experience (STE) such as an out of body experience, near death experience, kundalini awakening, vision or mystical experience -- not induced by a psychoactive substance? if so, please explain
*
Have you taken Ayahuasca before? How many times? Briefly describe your experience.
*
Why do you want to work with Ayahuasca?
*
I agree that the above statements are true, and failure to disclose medical information can have serious health consequences
*