Women's Retreat Intake Form
Please provide the following information to help us coordinate for your arrival. 
Sign in to Google to save your progress. Learn more
Full name *
Email address *
Telephone number (for Whatsapp, preferably) *
Age *
Nationality *
Where did you hear about Alma Healing Center or CoCrear? *
Required
Do you have any food allergies? *
If so, what are they?
What is your diet preference?
Clear selection
What are your reasons for participating in this retreat? What do you expect to get from the retreat? *
Will this be your first ayahuasca or DMT experience? *
Will this be your first San Pedro / wachuma or mescalin experience? *
If this is NOT your first experience for either or both of these, how would you describe previous experiences?
Do you need Spanish to English interpretation? *
Emergency Contact Information
In the case of an emergency, please let us know who you want us to contact for yo
Emergency Contact Name *
Relationship to you *
Emergency Contact Email *
Emergency Contact Phone Number *
Physical/Psychological/Health Condition
In this section, please highlight any physical or health condition that applies from the options below. This will help us make sure you are suited for the retreat.
Do you suffer from low blood sugar / hypoglycemia? *
Do you have a history of schizophrenia? Or does a member of your family? *
Physical or Health Condition you had or that you currently have *
Required
Have you ever undergone Gastric Bypass Surgery?
Clear selection
Psychological Condition *
Required
Are you currently taking or have your been prescribed any medications for any of the above psychological conditions? If so, please briefly describe below *
Are you currently taking or have you recently stopped taking anti-depressant medication? *
If so, please specify which medication *
Have you ever been diagnosed, treated, or self-identified with drug addiction/abuse? * *
If so, please provide us with some additional information about the types of drugs, date(s), or time span of addiction and your experience of any therapy or rehabilitation you have undergone to heal. *
Is there anything else you'd like to share with us?
Agreement
With this registration form, I declare that I come of my own free will and with full knowledge of the activities in which I will participate, as proposed during the Alma Healing Center and CoCrear Spiritual Retreat, including both ancestral ceremonies and alternative therapies. I further declare the following:
I am not consuming any psychiatric medications or drugs that have been identified by the gathering organization as potentially dangerous when taken in conjunction with ancestral medicines. If I am consuming psychiatric medications or drugs, I will specify the dosage and type to the retreat organizers. *
I do not have any psychological or mental problems that have not been reported to the retreat organizers. *
I do not have any previous or current physical or health condition that has not been reported to the retreat organizers. *
I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca, San Pedro, Peyote or other plant medicine. *
I release CoCrear and Alma Healing Center from any responsibility for accidents, dangerous circumstances, theft or other situations that may threaten my physical or mental integrity during the retreat, including transportation to and from the retreat center. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms