Questionnaire

Country

I speak English
yesno

Gender
MaleFemale

Date of birth

On desktop computers, use the scrollwheel within the dropdown next to the month-year selection. On mobile devices, please tap on the year in the blue bar to easily select your year of birth.

How did you hear about us?
FacebookInstagramGoogle SearchRetreat GuruFamily and/or friendsOther

If you haven't already reserved your spot, what is (are) your preferred retreat date(s)?

I want to sign up for
5-day ayahuasca and san pedro retreat5-day psilocybin retreat4-day psilocybin retreat3-day ayahuasca retreat3-day psilocybin retreatPrivate Psilocybin retreatPrivate Ayahuasca retreat

Do you have a physical or mental illness?
noyes
[group ill]
If yes, which and for how long?

[/group]

Have you, or one of your family members, ever suffered from one or more of the following symptoms or illnesses?

noyes
[group radio-symptoms]
If yes, which and for how long?

[/group]

Are you currently undergoing any medical or therapeutic treatment?
noyes
[group mecial-treatment]
If yes, for what reason?

[/group]

Are you currently taking any medication, including nasal sprays or pain relief?
noyes
[group take-medication]
If yes, which, how often, and what for?

[/group]

Do you regularly drink alcohol or take drugs?
noyes
[group take-alcodrugs]
If yes, in what quantities and how often?

[/group]

Ayahuasca is not compatible with the consumption of alcohol or drugs as well as some illnesses or medication. As the safety and well-being of all our guests is our highest priority, we may ask you to stop the consumption of alcohol, drugs and/or medication. Therefore, it is important to have your consent for the following:

I declare that I am willing not to consume any alcohol, drugs or medication for at least three days before attending the ayahuasca retreat (even up to two weeks in some cases), and that I am prepared to obtain consent from my doctor to take part in the session when this is requested from me by Acsauhaya:
noyes

Do you suffer (or have you suffered) from high blood pressure or heart diseases (in the past)? Please describe what complaints you have (had).

Do you have any experience with taking ayahuasca?
noyes

Do you have any experience with psychedelics?
noyes

Could you tell us something about your motivation to participate in our retreat?

I declare that I have fully and truthfully completed this form.
yes

I hereby agree to the Acsauhaya Retreat Agreement and the General Terms and Conditions*
yes

[multistep Q2EN last_step send_email]

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