Questionnaire

“We strive to respond within 48 hours …”

For the safety and well-being of all guests, it is required that you disclose, in confidence, any known medical conditions and/or use of any drugs or medication, at the time of booking. Therefore, we ask you to fill out the following questionnaire as accurately as possible.

Certain drugs, medications and medical conditions have been found to not be compatible with ayahuasca. (Please check our Dietary Guidelines for more information) In some cases you can not attend our retreats before you have stopped taking certain substances and have given time for your system to remove them from your body. However: you should always consult your 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 done by yourself.

If you have any questions, we will be glad to answer them.

We review the (medical) situation of each participant, before we finalize your booking and confirm your attendance to one of our retreats. After receiving your information, we try to schedule your requested date and finalize your booking as soon as possible. We strive to respond within 48 hours.

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?

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

I hereby agree to the General Terms and Conditions*