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RETREAT INTAKE FORM

Please answer this questionnaire honestly and with attention to detail, particularly for any questions pertaining to prior experiences, medical conditions and medication.

This information is used to assess the suitability of ayahuasca as safe and appropriate for you, and also to provide us with the information we need to fully support and assist your journey.

This information will remain strictly confidential.


Birthday
Day
Month
Year
1. Do you have any dietary restrictions?
YES
NO
2. Are you allergic to specific foods?
YES
NO
3. Do you have any severe allergies or conditions that require an Epi-Pen?
YES
NO
5. Have you had ayahuasca before?
YES
NO
6. Have you had any prior experiences with any of the following: psilocybin (mushrooms), mescaline, ketamine, mdma or LSD?
YES
NO
8. Are there any examples in your life, or your family of the following: Schizophrenia, DID, Psychosis, Obsessive Compulsive Disorder, Bipolar Disorder, insomnia or Epilepsy? "Yes" answers are not in any way disqualifying.
YES
NO
10. Are you currently taking an SSRI antidepressant or any medications that contains an MAOI?
YES
NO
12. Are you or have you been receiving therapy or attending any kind of support group?
YES
NO
13. Do you remember any traumatic childhood experiences (physical, emotional, psychological, sexual, medical)?
YES
NO
14. Have you had any traumatic experiences as an adult (physical, emotional, psychological, sexual, medical)?
YES
NO
15. Have you ever been diagnosed, treated, or self-identified with a substance addiction?
YES
NO
16. Have you ever been experienced addiction to anything other than substances/drugs (e.g. work, food, sex, phone, gambling)?
YES
NO
17. Have you ever been considered taking your own life? "Yes" answers will not in any way disqualify you from joining a retreat or dieta.
YES
NO

Note: Working with ayahuasca can involve intense experiences accompanied by strong emotional and physical releases. It is not recommended for people with cardiovascular problems, serious hypertension, certain psychiatric conditions, certain recent surgeries, acute infectious diseases or epilepsy. Some medications pose serious health risks if consumed before, during, or immediately after ayahuasca. There is no empirical research data on the safety of ayahuasca in preganant women.

I have disclosed all prescribed and non-prescribed medications and medical treatments that I am currently taking or receiving (and will indicate to Amakaya if this status changes)
I AGREE
I have disclosed all diagnosed and undiagnosed health conditions that I currently have or have had (and will indicate to Amakaya if this status changes).
I AGREE
I have completed this form myself, have answered truthfully, and understand that withholding or misrepresenting information could result in serious complications when drinking ayahuasca,
I AGREE
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