Sacred Sanctuary Intake Form

Please read the information on this page before getting started.

The following form helps us understand a little bit more about you and how we can best ensure that you have a safe experience during our sacred ceremonies.

You are required to complete this intake form before you will be eligible to participate in any of our sacred ceremonies.

All of your responses are entirely confidential. Please read each question and answer carefully.
Sacred Sanctuary Intake Form
Acknowledgement
I acknowledge that I am choosing to participate in ayahuasca ceremonies held by Sacred Sanctuary and its team. I agree to answer all the questions below honestly and that I must complete this form before being formally accepted as a participant. I agree to provide all the requested medical information regarding my mental and physical health. I agree to provide any updated information on my health up to the date of the ceremony retreat. I understand that based on the information provided in this form, and on the updated information, I may be excluded from participation in the requested ceremony retreat if Sacred Sanctuary and its team deem that it may not be safe for me to participate in the selected weekend.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Select desired retreat date:*

Private
Accommodations - Our retreats offer shared accommodations. Please select all that apply.*

I snoreI utilize a sleep aid (e.g. cpap)I prefer to camp outsideNone of the above apply to me
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birth date*

MonthDayYear
Date
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Is your Emergency Contact informed that you are attending an Ayahuasca retreat?*
In case of a medical emergency, may we disclose your personal health information to emergency medical personnel and your emergency contact?*
Where did you hear about us? If you were referred by anyone, please list their name.
Please list any dietary restrictions, allergies and preferences you have for the retreat. Note: All food prepared during our retreat is gluten-free and dairy-free.
Other non-food related allergies: Please list all allergies. i.e. animals, medications, chemicals, etc. Note: There are 2 dogs on our property.*
Select, food preferences for chicken and eggs. Both are served during our retreats.*

I do not eat chickenI do not eat eggsI eat both chicken and eggs
Please upload an updated picture of yourself.
Picture upload*

Cancelof

Plant Medicine Experience

Please answer the following questions regarding your plant medicine experience.
Have you ever participated in an Ayahuasca ceremony? If so, please state when and where.
Please give a brief explanation as to why you wish to participate in an Ayahuasca retreat?
Do you have any prior history with plant medicines or psychedelic substances?Please describe your history, if applicable.
Have you ever had a severe adverse reaction to any psychedelic substance or recreational drug? If so, please describe.
Please use this space to include any additional information that you think we should know about you.

I commit to discontinue the use of alcohol, marijuana, recreational drugs and non-prescription medications for a minimum of 2 weeks prior to my desired retreat weekend. I understand that many street and recreational drugs are strongly contraindicated with Ayahuasca and can be very dangerous and potentially fatal when combined.

For any prescription medications, I commit to consulting my primary care physician and will follow any recommendations for continuing or discontinuing usage prior to and after my weekend retreat.

I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca up to and including death.

I attest that I have read the Sacred Sanctuary Cancellation Policy below.

SACRED SANCTUARY CANCELLATION POLICY

Coordinating all the required resources for your retreat weekend takes considerable time and resources. No refunds or discounts will be provided if you fail to arrive on time, cancel or do not show for your retreat. If you require to cancel your participation for any reason, the cancellation policy below will apply without exception.

IF YOU CANCEL:
14 days or more prior to the start date of the retreat: 100% of the deposit amount you paid for the retreat will be transferred applied towards another a future retreat scheduled within 12 months from the date of the retreat in which you canceled. If you do not reschedule a future retreat within 12 months, you forfeit 100% of the deposit money you paid.

2-13 days prior to the start date of the retreat: 50% of the deposit amount you paid of for the retreat will be applied towards another a future retreat scheduled within 12 months from the date of the retreat in which you canceled, and the remaining 50% of the deposit will be forfeited.

24 hours or less prior to the start date of the retreat: No refunds or credits will be given, and you forfeit 100% of the deposit amount you paid for the retreat. No future rescheduling, and No credits will be given. Participants who fail to timely contact Sacred Sanctuary regarding a cancellation and fail to show
up for their assigned retreat weekend will NOT be given any refund, credit or be able to apply the deposit amount paid toward a future retreat date.

To cancel, you must send an email stating that you wish to cancel to: norelle@sacredsanctuaryretreat.com or lora@sacredsanctuaryretreat.com.

IF WE CANCEL:
If Sacred Sanctuary must cancel a retreat, you will be refunded 100% of paid funds. Compensation for airfare, hotel and other travel related costs incurred will not be refunded. In the unlikely event that we must cancel a retreat due to a force majeure event that is out of the control of Sacred Sanctuary (i.e. inclement weather, natural disaster, political upheaval, pandemic, epidemic, etc.) refunds are not guaranteed and may be issued at Sacred Sanctuary's sole discretion only. Sacred Sanctuary maintains the right to apply your paid funds to a future retreat at its sole discretion.
CHURCH MEMBERSHIP

I affirm that by completion and signing of this intake form, I accept membership as part of Sacred Sanctuary.

I also affirm that by signing this intake form that I have answered all the questions truthfully. Should any information in this form change, I will update Sacred Sanctuary.
Signature

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Pay Your Deposit

To reserve your spot, please send a 50% deposit to Sacred Sanctuary. You will be redirected after you Submit your form to our website for payment. Note: Your spot will not be reserved for your requested retreat date until we receive your deposit.
Should be Empty:

Sacred Sanctuary Intake Form

Acknowledgement

Please upload an updated picture of yourself.

Medical History

Mental Health and Drug Use

Plant Medicine Experience

Pay Your Deposit