Retreat Screening Survey

Retreat Application and Well-being Survey
Thank you for your interest in joining our ayahuasca retreat. To ensure your safety and a supportive environment, please fill out this form as completely and honestly as possible. Your information will remain confidential and is essential for determining whether this experience is suitable for you.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Place where you would like to attend the retreat?
What is the primary reason you want to participate in a retreat?*

To heal emotional woundsTo explore spiritualityTo gain self-awareness and personal growthTo address a specific mental or physical health issueCuriosity about PsychedelicsMental Health SupportShamanic ExperienceDealing with AddictionOther
What are your specific intentions or goals for this retreat?*
Are you interested in a full retreat with therapeutic support, or only in the ayahuasca ceremony?

Full retreat with therapeutic supportOnly the ayahuasca ceremonyOther
Have you attended any other spiritual or personal development retreats?*

YesNo
What do you know about entheogens, including ayahuasca?*

I have extensive knowledge and experienceI have some knowledge but no personal experienceI know very little and am seeking to learn moreI have no prior knowledge
How many times have you done ayahuasca?
Do you have any fears or concerns about the ayahuasca experience?*

Fear of losing controlFear of confronting difficult emotions or memoriesFear of physical side effectsNo fears or concernsOther
If yes, please describe the retreat(s):
Have you previously used psychedelics (e.g., ayahuasca, psilocybin, LSD, etc.)?*

YesNo
If yes, what substances have you used?

AyahuascaPsilocybin Mushrooms (Magic Mushrooms)Sanpedro (Wachuma)LSD (Lysergic Acid Diethylamide)MDMA (3,4-Methylenedioxymethamphetamine)DMT (N,N-Dimethyltryptamine)Mescaline (from Peyote or San Pedro cactus)5-MeO-DMT (from Bufo Alvarius toad or synthetic)KetamineIbogaine (from Iboga plant)Salvia Divinorum2C-B (4-Bromo-2,5-Dimethoxyphenethylamine)Please specify:
Have you experienced any challenging or difficult psychedelic experiences?*

YesNo
If yes, please describe:
Do you have any chronic medical conditions (e.g., heart disease, diabetes, hypertension)?*

YesNo
If yes, please describe:
Are you currently taking any medications?*

YesNo
If yes, please list them:
Have you had any recent surgeries or medical treatments?*

YesNo
If yes, please describe:
Do you have any history of seizures, strokes, or neurological conditions?*

YesNo
If yes, please describe:
Do you have a history of any mental health conditions (e.g., depression, anxiety, PTSD, bipolar disorder, schizophrenia)?*

YesNo
If yes, please describe:
Are you currently taking any medications for mental health conditions (e.g., antidepressants, mood stabilizers, antipsychotics)?*

YesNo
If yes, please list:
Have you received psychotherapy in the past? If so, what type and what was the reason?*

Yes, cognitive-behavioral therapy (CBT)Yes, psychoanalysisYes, trauma therapy (e.g., EMDR)No, I have not received psychotherapyYes, other (please specify): __________
If yes other, please describe the type of therapy and frequency:
Have you ever been hospitalized for mental health reasons?*

YesNo

Do you use any psychoactive substances? If so, which ones and how often?

Rows	Daily	Weekly	Seldom	Never
Alcohol
Cannabils
Tobacco
Psychedelics
Stimulants
Opiates
Other

In case of having any addictions please describe below:
How do you currently manage stress and emotions?
Do you have any experience with meditation, yoga, breathwork, or other spiritual practices?*

YesNo
If yes, please describe:
Have you worked with any healers, shamans, or spiritual teachers?*

YesNo
If yes, please describe:
Do you participate in any support groups, therapy groups, or personal development programs?*

YesNo
If yes, please describe:
If yes, please describe:
Do you have any fears or concerns about participating in this retreat?*

YesNo
If yes, please describe:
Please write in detail what motivates you and your expectations from the retreat.*
Signature*
This screening form aims to ensure participants are physically, mentally, and emotionally prepared for the retreat and helps the facilitators create a safe and supportive environment for all.
Should be Empty:

Retreat Application and Well-being Survey