Participant Application for Session

Name*

First

Last

City*

Province/State/Region*

Country*

Date of Birth*

day

/

month

/

year

Today's Date*

Email

Phone

Do you currently suffer from any cardiovascular disease or have had a heart attack?*

Yes

No

If YES, Please Indicate or provide history*

Do you have high blood pressure?*

Yes

No

Please indicate if you have any psychiatric condition(s)*

Yes

No

If YES please provide details*

Have you had any recent surgeries or operations?*

Yes

No

Please indicate your surgeries or operations and when *

Have you had or do you have any significant physical injuries or impairments? *

Yes

No

Please indicate your injuries or impairments*

Do you have any infectious or contagious diseases?*

Yes

No

Please indicate infectious or contagious diseases *

Are you pregnant?*

Yes

No

Have you been hospitalized in the last 10 years for any physical conditions?*

Yes

No

If Yes, what were you hospitalized for and when? If multiple times, please indicate why and approximate month/year.*

Have you ever been hospitalized for a psychiatric condition or event?*

Yes

No

If Yes, what psychiatric condition/event were you hospitalized for and when? If multiple times, please indicate why and approximate month/year.*

Is there anyone in your family history with a history of severe psychiatric disorders or conditions?*

Yes

No

Are you currently receiving therapy or attending any kind of support group?*

Yes

No

If Yes, what therapy or support group are you attending?*

Are you taking any medication(s)?*

Yes

No

If Yes, please indicate the medication(s) you've been taking and for how long?*

Is there anything else about your physical or emotional state that the facilitator should be aware of?*

Yes

No

If Yes, please indicate what physical or emotional conditions your facilitator should be aware of prior to you going to the Session.*

Have you ever taken ayahuasca before?*

Yes

No

If Yes, please indicate the number of times you've taken ayahuasca and the circumstances. *

Did you have difficulty integrating your ayahuasca experience(s) or did you experience any significant adverse effects?*

Yes

No

If Yes, please outline any adverse effects or difficulties with integration.*

Have you taken other psychoactive substances and had difficulty integrating or processing the experience?*

Yes

No

Please indicate the substances you used and what adverse experiences you had? *

Do you take any other legal or legal recreational drugs on a regular basis?*

Yes

No

Please indicate the substances you use on a regular basis.*

Please provide a name and contact number for a next of kin or emergency contact should problems arise in the Session. If none, state "None"*

Please read and acknowledge the following declaration - I declare that I have read and understood the information in this form. I further declare that I have answered all the above questions fully and honestly and have not withheld any information that I believe could be important. *

Yes I have answered honestly and completely