JUNGLE MEDICINE RETREAT

JUNGLE MEDICINE RETREAT

Please read and e-sign the documents below
Plant medicines (Ayahuasca, Psilocybin, San Padro, Sananga, Cannabis, Mapacho, Tobacco, Rapé, etc.) sessions are intended to be a personal growth experience and should not be considered a substitute for psychotherapy, but rather a complementary therapeutic device. Working with plant medicines can involve intense experiences accompanied by strong emotional and physical releases. It is not recommended for people with cardiovascular problems, serious hypertension, psychiatric conditions, recent fractures or surgery, acute infectious diseases, epilepsy or active spiritual emergencies. There is no data on the safety of plant medicines in pregnant women. For more information about plant medicines, please visit www.iceers.org. If you have any doubt as to whether you should participate in the session, it is essential that you consult your doctor or therapist, as well as the organizers of the session. It is important in order to ensure your safety whilst on retreat that we have full knowledge of any psychological health conditions you are currently experiencing or have done in the past. Please be as honest as possible when answering the following questions. You can be assured that your information will remain confidential and is used only to determine whether plant medicines are the right fit for you now.
Name

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
Date
Email
example@example.com
Phone Number
Marital Status:*

SingleDomestic PartnerMarriedDivorcedSeparatedWidowed
Gender:*

MaleFemale
Emergency Contact and Phone Number & Email
Is your emergency contact aware of your plant medicine Retreat?
In case of an emergency may we disclose your personal health information to Emergency Medical Personnel and your Emergency Contact?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred contact method:

Mobile PhoneEmail
For Veteran
What is the date of the retreat you are attending?

MonthDayYear
Date
Are you currently under the care of a family physician or any other health professional?*

YesNo
If "Yes", please indicate:
Please list any prescribed medications you take (Name, Dosage, How Long?):
Please list all non-prescription medications you take(Name, Dosage, How Long?)::
Please list any supplements you currently take or have taken in the recent past (Name, Dosage, How Long?):
Your habits. Please describe, when applicable:
Have you been diagnosed with any of the following conditions?

DiabetesEpilepsyHeart conditionCancerBleeding disorderThyroid conditionIrritable bowelUlcerative colitisLiver diseaseAsthmaHIV / AIDSOsteoporosisRheumatoid arthritisKidney diseaseCardiovascular disease
If "other(s), please specify
Please tick the boxes which indicate conditions you have had or presently have. If any other conditions, please list them on the box down below:

AbscessesAcneAIDS/HIVAlcoholismAllergiesAmnesiaAnemiaAnginaAnxiety disorderArthritisAsthmaBladder infectionsBronchitisCancerChicken PoxCold SoresColitisDepressionDiabetesEating disorder EczemaEczemaEmphysemaEpilepsyGall StonesGoitreGonorrheaGoutHay FeverHemorrhoidsHeart DiseaseHepatitis A, B or CHerpesHerpes GenitaliaHigh/Low Blood PressureHypoglycemiaInfluenzaKidney DiseaseKidney StonesLeukemiaMalariaMeaslesMigrainesMiscarriageMononucleosisMood disorderMumpsParasitesPelvic Inflammatory DiseasePeritonitisPleurisyPneumoniaPost‐partum depressionProstatitisRheumatic FeverRubellaScarlet FeverSchizophreniaSexual AbuseSkin DiseaseStomach problemsStrep ThroatSinusitisStrokeSun StrokeSyphilisTonsillitisTuberculosisTyphoid Fever Venereal WartsUlcersVenereal WartsWartsWhooping CoughWormsYellow FeverOther(s)CHFCOPDBI-PolarAlcohol DependencyDrug DependencyHIV/AIDSSeizure HistoryTraumatic Brain InjuryHead TraumaOther
If "other(s), please specify
Are you allergic to anything? (e.g.: foods, medications, pollens, chemicals, moulds, animal hair, etc.)
Explain if you suffer from any mental illness (depression, bi polar, schizophrenia, obsessive compulsive disorder, paranoia, psychosis, suicidal tendencies, multiple personality disorder, chronic anxiety, PTSD, clinical depression, borderline personality disorder, chronic anxiety, self harming, etc.)?
Are you currently taking ANY anti depressant medications OR supplements currently prescribed or self administered and the duration you have been taking them (including phenibut, psilocybin, cannabis, ketamine, etc)? Please list the dosage and length of time you have been taking them. *
Have you dealt with any of the following emotional / behavioural problems? Check all that apply:

Alcohol abuseChronic lyingDistrustfulDrug useExtreme worrierHostile/angry moodImmaturityImpusivityIndecisivenessNot trustworthyRepeats words of othersSelf-injurious actsStealingViolent temperOther(s)
If "other(s), please specify
Do you have any difficulties with alcohol, drugs or food? If yes, please dissert about such difficulties.*
Substance usage status:

No history of abuseActive abuseEarly partial remissionEarly full remissionSustained partial remissionSustained full remission
Which - if any - of these substances do you currently use or have used in the past? Please use the box to indicate your age at first use and age at last use. (E.g.: Alcohol - 16, 30)

AlcoholAmpheteminesBarbiturates/OwnersCaffeineCocaineCrack cocaineHallucinogens (e.g., LSD)Inhalants (e.g., glue, gas)Marijuana or hashishNicotine/cigarettesPCPOther(s)
Do you use any recreational drugs? Which?
Have you ever attempted suicide, had suicidal thoughts or self harm?
Have you ever had a spiritually transformative experience (STE) such as an out of body experience, near death experience, kundalini awakening, vision or mystical experience -- not induced by a psychoactive substance? if so, please explain *
Have you taken the Plant Medicine before? How many times? Briefly describe your experience. *
WHY do you want to work with the Plant Medicine?*
I will discontinue all use of alcohol, marijuana, recreational/street drugs and non-prescribed pharmaceuticals at least two weeks prior to coming to Jungle Medicine Retreat. * I understand that many street and recreational drugs are strongly contraindicated with plant medicines and can be very dangerous and potentially fatal when combined.*

Clear
By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.
I understand that Jungle Medicine Retreat staff may require me to take a drug or breathalyzer test prior to or during a retreat, without prior notice or reason. If I refuse to comply with the test or the results come back positive I may be denied entry to the retreat, or be expelled from the retreat immediately. In this case I will not be eligible for a refund.**

Clear
By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.
I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking plant medicines up to and including DEATH.*

Clear
By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.
Please upload your Driver Lic. or Id card to verify your identity*

Cancelof
Please upload your Credit card you intend to use. Name must match your ID or Driver LIC. For extra protection, you can cover or blackout the first 12 numbers *

Cancelof
By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

Clear
Should be Empty: