Peru Sacred Medicine Retreat

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Peru Sacred Medicine Retreat - 2024

Thank you for your interest in the upcoming retreat next December 1 - 12, 2024. Please note that this specific journey will be prioritizing Black, Indigenous, and People of Color (BIPOC) as these groups rarely get to enjoy the privilege of retreats of this type. That said, it will be a mixed space that will include White allies/accomplices, who are far along in their understanding of Social Justice and the impact of colonization and systemic racism on Black and Brown bodies. The group is limited to 16 participants.

There are health-related questions on this form. Please note that this form does not meet requirements for protected private health information.

Email *

Telephone

May we contact you for additional info, if necessary?

Name

Preferred to be called:

Pronouns

Do you have any disabilities that we might accommodate for? Please explain, if applicable.

How do you identify? (Race, Ethnicity, Gender..)

Do you have a current passport? If so, when does it expire?

Where do you currently live?

Who were the original inhabitants of the land you now occupy?

What is your experience, if any, working with Sacred Plant Teachers?

What is calling you to this work and to joining this group specifically?

What is your experience, if any, with liberation work and social justice?

What is your experience being in culturally diverse spaces?

FOR WHITE-IDENTIFIED PARTICIPANTS: What is your comfort level in honoring and prioritizing Black, Indigenous, & Brown persons' experiences and voices, while holding a safe space for them, even as uncomfortable feelings come up?

I am not comfortable prioritizing one person's experience over another. We are all the same.

I sometimes feel that Black, Indigenous, and Brown individuals can be accusatory in sharing their experience.

I am currently doing the personal work of unpacking systemic racism within myself and I'm learning to honor the experience of historically oppressed/marginalized populations, even though it sometimes feels difficult.

I am all in for supporting and holding safe space for BIPOC and have been doing this work for several years now. I understand that this is a long journey and I still have a lot to learn.

Other:

Clear selection

FOR BIPOC PARTICIPANTS: How comfortable are you sharing your experience (if any) of systemic oppression in diverse groups?

I've never experienced systemtic oppression.

I am not comfortable sharing my experience.

It is uncomfortable for me to share, but I know that in safe settings we can all learn from what I share.

I am growing more comfortable each day sharing about these difficult/traumatic experiences in public forums and mixed spaces.

Clear selection

Can you share a little about your spiritual practices and belief systems?

What is your comfort level with Spiritual practices, ritual, ceremony, and communing with unseen forces? Can you briefly share about any experience you might have in this regard?

Do you have any past or current medical conditions? Please list if you're comfortable sharing:

Are you currently taking any medications? Please list:

Have you ever been diagnosed with a mental health condition? Please explain:

Do you have a history of trauma? If so, please briefly explain.

Have you received healing support for any mental health or trauma-related conditions? If so, please explain.

Do you have current supports in place that sustain you in your healing journey?

Are you familiar with foreign travel, particularly in the Southern Hemisphere? Please briefly share about your experience.

This type of journey requires dietary restrictions including abstinence from substances such as alcohol and Cannabis. If you partake in these practices, are you confident that you are able to abstain from these practices for an extended period of time?

If you had questions for us, what would your questions be?

Send me a copy of my responses.

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