AYAHUASCA CEREMONY - Intake Form

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AYAHUASCA CEREMONY - Intake Form

Anyone who wishes to participate in this experience must complete this intake
form. The purpose of this assessment is to keep you and this sacred work safe. The information
collected will help your primary facilitator to understand potential contraindications and side effects
in order to prevent any unforeseen issues before they occur and all information remains
confidential. What is prescribed for you and how you feel are extremely important us. Please be

honest with your answers and if you have questions, please reach out directly,

AS A PARTICIPANT:

I UNDERSTAND THAT THE INFORMATION PROVIDED HEREIN WILL ONLY BE USED TO DETERMINE
IF IT IS APPROPRIATE FOR ME TO PARTICIPATE IN GROUP OR PRIVATE EXPERIENCES AND
WHOM TO CONTACT IN AN EMERGENCY. THIS INFORMATION IS MY CONFIDENTIAL
INFORMATION AND IT WILL BE USED TO ASSESS THE TYPE OF EXPERIENCE THAT WILL WORK
BEST FOR ME.
I MUST KEEP MY FACILITATOR INFORMED OF ANY CHANGES TO MY MEDICAL HISTORY
BEFORE I ATTENDING THIS RETREAT/CEREMONY EXPERIENCE. WHEN IN DOUBT OF WHAT TO
REPORT, I WILL CONTACT THE PRIMARY FACILITATOR.

PLEASE COMPLETE EVERY ITEM IN EVERY SECTION. PLEASE COMPLETE THIS FORM TO ACCESS THE DOWNLOADABLE FILES.

Poster

Please complete your registration by sending an energetic deposit of $317 via Venmo. The Total Investment for the Ceremony is $634, including food and despacho offerings.

I appreciate your interest in joining this life-changing experience. We look forward to sharing a meaningful moment with you. Untitled Title

Once payment is received, your registration will be confirmed.

Grandmother Medicine

FIRST NAME
*

LAST NAME
*

DATE OF BIRTH

YYYY

ETHNIC BACKGROUND
*

PHONE NUMBER
*

HOME ADDRESS
*

EMERGENCY CONTACT PERSON AND PHONE NUMBER
*

RELATIONSHIP WITH THE EMERGENCY CONTACT PERSON
*

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