Questionnaire

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Medical Questionnaire

To ensure the safety and well-being of our guests and to optimise their psychedelic retreat experience, we kindly request all applicants to complete a medical questionnaire. We want to emphasise that having pre-existing conditions does not automatically disqualify anyone from participating. However, it is crucial for us to be aware of any contraindications that may pose potential risks to our guests. As such, we kindly request that you be as accurate as possible when filling out the questionnaire below.

If you have any concerns about the information provided, we are here to address them and find the best way forward, ensuring your experience is as safe as possible. Please take a moment to fill out the questionnaire below, and rest assured that all the information you provide will be treated with utmost confidentiality in accordance with data protection regulations and GDPR.

Certain drugs, medications and medical conditions have been found to contraindicate with certain entheogenic plants and fungi (ayahuasca, psilocybin).

In some cases you may not attend our retreats before you have stopped taking certain substances and have given time for your system to remove them from your body. (Please check our Dietary Guidelines for more information on food substances). However, you should always consult a medical professional before abruptly discontinuing the usage of prescribed medications. Please reserve sufficient time to carefully fill out the questionnaire below. This should only be completed by the person attending the retreat.

If you have any questions, please do not hesitate to contact us via email or whatsapp.

We review all questionnaires on case-by-case for each participant before finalising your booking and confirming your attendance. After receiving your information, we try to schedule your requested date as soon as possible.

Please allow some time for the form to be sent; do not close your browser window before you see the confirmation message.

*Please note that our email may have ended up in your spam or junk folder. If it seems like we haven’t gotten back to you, please check these folders as well. Sorry for the inconvenience!

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    Do you have a physical or mental illness?

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

    • Psychosis

    • bipolar disorder

    • borderline disorders

    • schizophrenia

    • mania

    • hallucinations

    • severe anxiety

    • severe depression

    • suicidal thoughts or actions

    Are you currently undergoing any medical or therapeutic treatment?

    Are you currently taking any medication, including nasal sprays or pain relief?

    Do you regularly drink alcohol or take drugs?

    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:

    Do you have any experience with taking ayahuasca?

    Do you have any experience with psychedelics?

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

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