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Intake, Waiver and Release Form for Ceremony - April 27th 2024
This m
edical
s
creen
intake and waiver m
ust be completed prior to
the start of each
ceremony
. Even if you have participated in a ceremony with us before, a new intake form must be completed prior to each ceremony.
ALL RESPONSES ARE
KEPT
CONFIDENTIAL AND PRIVATE.
THIS INFORMATION WILL NOT BE SHARED WITH A THIRD PARTY.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Phone Number to follow up for a short call. Include Country Code (US and Canada +1)
*
Your answer
Is your phone number linked to a WhatsApp Account?
*
Yes
No
Required
Do you have experience with plant medicine or psychedelics?
*
Yes
No
Required
If yes to the previous, what plants or substances have you used socially or in ceremony? List all substances (Example : alcohol, cannabis, cocaine, mushrooms, MDMA, ayahuasca, kanna, etc...)
Your answer
What prescription medications are you taking? (list all here as well as amount and how often you take them)
*
Your answer
What over the counter medications are you taking? (list all here as well as amount and how often you take them)
*
Your answer
What herbs and supplements are you taking? (list all here as well as amount and how often you take them)
*
Your answer
Do you have a history of schizophrenia, psychosis, bi-polar
condition,
seizures,
or other mental health diagnosis
?
*
Yes
No
Other:
If yes to prior question provide details.
Your answer
Do you have a heart condition or a history of heart problems (choose all below)?
*
Yes
No
Angina
Heart Attack
Heart Failure
Arrhythmia
High Blood Pressure
Congenital heart conditionn
Other:
If yes to prior question provide details.
Your answer
Are you pregnant?
*
Yes
No
Do you have any food restrictions?
Your answer
Do you have any food allergies?
*
Yes
No
If yes to above, please list.
Your answer
Are you a Costa Rica resident (live in Costa Rica 10 out of 12 months a year), citizen, or visitor
*
Resident
Citizen
Visitor
Other:
How many days will you be staying in Costa Rica after the ceremony? (We strongly suggest allowing at least 1 full day of integration post ceremony before taking a long trip or flight)
*
Your answer
In order to secure your spot for this ceremony a $100 non-refundable deposit is required. Please indicate that you have read the statement of deposit.
You can pay with Zelle ( paul.jarreau@gmail.com ), Venmo ( @Paul-Jarreau ), or PayPal (friends and family payment paul.jarreau@gmail.com ), Revolut (@ronaldnikel)
*
Yes
No
Required
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