NYE Ceremony Application

If you do not have experience with the Grandmother Medicine, PLEASE READ the following document, Towards Better Practices, BEFORE you complete this lengthy application.

If you have any hesitancy, or medical contraindications, PLEASE KNOW THAT THERE WILL BE FUTURE CEREMONIES.

If this particular opportunity is not the time, there will be another.

PLEASE READ ALL OF THE FOLLOWING INFORMATION PRIOR TO APPLYING FOR THE CEREMONY.

It is necessary that you agree to disclose, in confidence, any known medical conditions and/or use of any medication, at the time of application.

Each application will be followed up by a phone call with a facilitator.

Certain drugs and medications have been found to not be compatible with Ayahuasca. It is essential to stop taking the following substances and give your system sufficient time to remove them from the body before you begin a workshop.

IT IS IMPERATIVE THAT YOU READ THE ATTACHMENT CONTAINING THE LIST OF MEDICATIONS, DRUGS, AND SUBSTANCES THAT ARE INCOMPATIBLE WITH AYAHUASCA.

Please consult your doctor if you are in any doubt: you certainly should not suddenly stop taking prescribed medications (including antidepressants) without consulting your doctor.

Visit Ayahuasca Forums for a comprehensive information page of medical, botanical and nutrition interaction guidelines.

Ayahuasca Forums Info

Please answer the following questions as completely and honestly as possible. Your responses will remain strictly confidential.

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Gender* This field is required.

Female

Male

Identify otherwise

Age* This field is required.

Emergency Contact* This field is required.

First and Last Name

Relationship

Phone Number

Current Physician* This field is required.

First and Last Name

Phone Number

Do you have a past history of, or currently suffer from any of the following? * This field is required.Important Medical Precautions The facilitators at this ceremony have many years of experience, in holding ceremonies, and in the safe use of Ayahuasca in its traditional context. Please note that in certain cases working with Ayahuasca can carry health risks: if you have any heart abnormalities of any type, liver or kidney disfunction, blood pressure irregularities, other serious medical problems it is important that you discuss at time of this submission. Many health concerns can be worked around, but it is imperative that the facilitator know in advance or you put yourself, and the group as a whole at risk.

Have you been hospitalized for medical reasons in the past 5 years? (If yes, please elaborate.)* This field is required.

Are you CURRENTLY taking any type of medications? If yes, please list all medications including dosage and frequency taken.* This field is required.**Please note that it is imperative that you provide an accurate and detailed list of medications, as Ayahuasca can dramatically increase the effects of certain medications to the point of becoming dangerous**

Are you taking Methylene Blue?* This field is required.

YESNO

Are any of your medications for a psychiatric disorder, SSRI medication for depression, or other issue?* This field is required.Examples: Prozac, Seroxat, Zoloft, Effexor, Paxil, Welbutrin (bupropion), Zyban ,Pristiq, Cymbalta, Ixel, Effexor, Tramadol, Tramal, Ultram, Sibutramine, Meridia, Reductil, Axiomin, Etonin, Lubazodone, Serzone, Nefadar, Trazodone, Desyrel, Strattera, Edronax, Vivalan, Focalin, Ritalin, Concerta, Adderall, Dexedrine, Desoxyn, Vyvanse, Elavil, Endep, Evadene, Clomipramine, Anafranil, Desipramine (Norpramin, Pertofrane), Amoxapine (Asendin), Maprotiline (Ludiomil), Mianserin (Bolvidon, Norval, Tolvon), Mirtazapine (Remeron), Isocarboxazid (Marplan), Moclobemide, Aurorix, Manerix), Phenelzine (Nardil), Pirlindole (Pirazidol), Selegiline , Eldepryl, Zelapar, Emsam, Tranylcypromine (Parnate), Lithium, or other

YESNO

Do you have any psychological conditions that we should know about, such as bipolar disorder, history of depression, PTSD, history of trauma, suicidal tendencies or thoughts, etc?* This field is required.PLEASE BE HONEST, AND IF YES WE WILL DISCUSS - THIS IS NOT A HARD BARRIER TO PARTICIPATION

YESNO

If yes, please elaborate + make sure this is discussed in in detail in your onboarding call

It is mandatory to read this attachment to prevent any conflict or contraindication to your current medications or supplements

I have read the SAFETY DIETA attachment containing the list of medications that are unsafe in combination with ayahuasca, and agree that I am not in contradiction to any of the incompatible substances* This field is required.One of the only ways that ayahuasca can harm you, is if you are on anti-depressants that are incontradiction. There are ways to work around this. Please be honest and we will do everything we can to get you to your natural path of healing by advising a plan or reduction or elimination

Yes

Possibly. Can we discuss?

List any supplements (herbs or vitamins) that you have taken regularly in the past 2 months.**. * This field is required.**Please note that it is imperative that you provide an accurate and detailed list of medications, as Ayahuasca can dramatically increase the effects of certain medications to the point of becoming dangerous**

Have you ever worked with any other psychedelic compounds?* This field is required.

ayahuasca

lsd

mushrooms

huachuma

peyote

ketamine

5Meo

no I have not

While Plant Medicines can facilitate extraordinary healing, and can provide healing not accessible by pharmaceuticals, the facilitator's guidance pre and post ceremony is not a substitute for psychiatric care, and should be considered emotional, holistic, and spiritual therapy. I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information.* This field is required.

I agree

I do not agree

Is there anything else about your physical or mental health that we should be aware of?* This field is required.

Please set intention for this special medicine ceremony once you have decided to join. Next you'll have a phone call with Jordana to discuss, explore, and commit to your intention?* This field is required.FEEL FREE TO SHARE

Can you commit to following a recommended food and lifestyle dieta prior to ceremony?* This field is required.Length of this dieta will be determined in your consultation phone call. Ideally 10+ days, Minimum 4 days.

YESNO

By making the decision to apply and to take part in this retreat with plant medicine ceremonies and its associated group activities, do you agree to absolve us of any responsibility and liability?* This field is required.

YESNO

Signature* This field is required.I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information I have read the attachment containing the list of medications that are unsafe in combination with ayahuasca, and agree that I am not in contradiction to any of the contraindicated substances. *Please note that ceremonies should not be seen as, nor are they designed to be, a substitute for psychiatric or medical care.

Clear

Once we have received your completed application we will follow up with a phone call to discuss the application.

[And if applicable, determine your accomodation preference, date of arrival, choice of add-ons, and arrangement for payment.]