Every Journey with the medicine is unique, what is the call from your heart for coming to Medicine at this time? What areas of your life are you calling in healing for at this time? (health, clarity on your life path, deepening of your spiritual practices, relationships, career, etc.)

Will this be your first time participating in an Ayahuasca Ceremony with the Shipibo Healers? If not, how were your previous experiences

Please give an estimate of how many Ayahuasca ceremonies you have attended in the past. *

What wellness and/or spiritual practices do you regularly engage in? (yoga, meditation, tai-chi, psychotherapy, music, art, exercise, gardening, journaling, a particular spiritual philosophy, etc

Please give details of your physical health history, reporting all serious diagnosed conditions and procedures, including any major surgeries, and any undiagnosed issues you feel are relevant. Also please share your physical fitness level as Hikes in the Jungle are part of this package *

Please share if you identify with any of the following Diagnosis

High Blood Pressure

Heart Surgery/Heart Attack (date)

Psychosis

Bi Polar Disorder

Dissociative Identity Disorder (Formerly known as Multiple Personality Disorder)

Schizophrenia

Suicidal Ideation (thoughts about suicide or attempts at suicde)

Psychotic Paranoia

Anxiety Disorder (panic attacks, OCD, etc)

Eating Disorder

PTSD

Self Harm

Further Information

Please share how long you have been experiencing these symptoms so the Maestros can best prepare your treatment plan

What is your current, subjective psychological status? (e.g. stable, hopeful, grounded, grateful, depressed, anxious, preoccupied, paranoid, etc.

Please list all current medications and supplements you are taking (Prescription, over the counter, natural, vitamins etc.). *

Medication History *

Please share any medications you have used long term, such as anti depressants, anti-anxiety medications etc and the time period you used them for and date you stopped taking them

Please give details of any substance abuse issues or addictions you have experienced or are currently experiencing. *

Please share what substances you are using or have been using

Cannabis

Cocaine

Phenethylamines (e.g. MDMA)

Heroin or non-prescription opiates

Methamphetamine

Have you ever been diagnosed, treated, or self-identified with alcohol use disorder? If so, please provide us with some additional information about your experience including the date(s) or time span of your addiction and whether you have undergone any therapy or rehabilitation to heal

Do you have any allergies to specific foods? If yes, please specify which foods and the reaction that results when you ingest the food

How would you describe your current state of physical and mental health? *

Do you have any severe or potentially life-threatening allergies that would require the use of an Epi-Pen? If yes, explain and bring the pen with you

Please explain in detail why you want to participate in an Ayahuasca ceremony i.e. further develop your relationship with the medicine, seeking healing of physical conditions, seeking healing of mental conditions, getting help to deal with past trauma, seeking spiritual development and exploration, seeking general personal development, seeking to develop your relationship with yourself etc. *

Will you be attending the retreat with anyone you know? Please provide names and your relationships. *

Do you speak any of these languages?

English

Spanish

Shipibo

Did you make a donation toward the construction of Jochipapanete? *

Yes

How did you hear about Jochipapanete? *

Additional Comments

Passport Number (required if flying to centre)

Agreements

I will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing

I will discontinue all use of alcohol, marijuana, recreational, street drugs and nonprescribed pharmaceuticals at least 3 weeks prior to commencing the retreat. I understand that many street and recreational drugs are strongly contraindicated with medicines like Ayahuasca and can be very dangerous and potentially fatal when combined

I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications.

Thank you!