Dieta Registration 
Please fill out this application form so we can start to get to know you, make sure this immersion will be the right container for you and support you in the best way.
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Email *
Legal First & Last Name *
Date of Birth *
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Whatsapp number *
Country of Origin *
Gender *
Where did you hear about this immersion? *
What are your intentions for our time together? 
What are your dreams for your life that we can support you with?
Are you holding a specific inquiry or asking for guidance in a particular part of your life?
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What are your passions and what is your work? *
In general, how satisfied are you with your life? *
What is your general state of happiness? *
What's your general stress level on a day-to-day basis *
If you had to choose from 2 emotions that you sense most frequently, what are they? *
What is your experience with plant medicine? Note - no previous experience is necessary - everyone will be given thorough information to ensure they feel prepared. You will be supported in a safe, compassionate and loving environment with no judgement where all of you is welcome. 
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How often do you take other state changing plants, substances, medicines, pharmaceuticals? Please describe your usage throughout your life and in the past 3 months? *
Do you have a spiritual, meditation, or yoga practice? If yes please share a bit. Note - this immersion is open for all levels of experience.
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Do you have any heart conditions? 
Have you ever been diagnosed with any physiological conditions such as bipolar disorder, schizophrenia, psychosis, OCD, PTSD, manic/depressive disorder, or depression? *
If yes, what have you been diagnosed with, when and what is your relationship to this diagnosis?
What is your relationship to depression or suicidal thoughts? Please share what you are comfortable with, keeping in mind this is confidential & will help us support you. *
Have you received counseling from a psychiatrist, psychologist, or counselor or been hospitalized for an emotional or psychological issue? *
If yes, when? Please share what you are comfortable with, keeping in mind this is confidential & will help us support you.
Have you experienced any emotional, physical or sexual abuse? *
If yes, which kind of abuse and when? Please share what you are comfortable with, keeping in mind this is confidential & will help us support you.
Can you briefly describe your childhood including your relationship with your parents?
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Are you currently taking any supplements, over-the-counter or prescription medications? If yes, what are you taking, what dosage and for what exactly?


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Are you currently taking any natural mood regulating precursors such as 5-HTP or medical mood stabilizers such as (but not limited to) Lithium, Antipsychotics, Antidepressants or Anticonvulsants? If so, please share details.
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Are you currently on SSRI’s (Selective Serotonin Reuptake Inhibitors) such as (but not limited to) Prozac or Oxactin? If so, please share details. 


Do you have a history of using any of these medications? If so, please explain in detail.


Have you ever experienced a seizure? *
If yes, please share details including when and what brought on the seizure.
Do you have asthma or any other respiratory conditions? *
Do you use an inhaler? If yes, please bring it with you. *
Have you been diagnosed with Diabetes? *
Which Type?
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Do you have High Blood Pressure? *
If yes, what are your typical numbers?
Do you have Low Blood Pressure? *
If yes, what are your typical numbers?
Have you been vaccinated in the past few years? 
Do you drink alcohol? *
If yes, how many drinks per week? *
Do you smoke tobacco? *
How often? *
Do you use rapé? *
How often?
Have you ever experienced substance abuse problems? *
If so, when? Please share what you are comfortable with, keeping in mind this is confidential & will help us support you. *
Do you have any dietary restrictions? *
Required
Do you have any allergies? *
If yes, what are you allergic to? *
Do you have people in your life that you can share and reflect with about your experience? *
Emergency contact Name *
Emergency contact Relationship *
Emergency contact Phone *
Is there anything else that you feel is necessary to share with us? *
Do you realize that failure to disclose accurate information could result in potential harm to yourself and/or fellow participants? *
Do you undertake full responsibility to notify us should there be any changes in your health status before the retreat? *
By clicking "Yes, I agree" you certify, warrant, and represent that the above information is a complete and accurate statement of your physical and psychological condition. You completing this Confidential Medical History Form is to ensure the safety of yourself & all those participating in the Meditation Retreat. The information provided on this form will be used for determining the appropriateness and safety of your participation in the Meditation. *
By clicking "Yes, I agree" this form releases the facilitation team and venue from all liability relating to any bodily harm, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence or not. By clicking "Yes, I agree" you forfeit all right to bring a suit against the facilitation team and venue for any reason. *
Thank you for sharing with us. We look forward to welcoming you to Yacumama! ❤️

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