Roots & Realms Women's Retreat Application Form
Welcome beautiful! I am so happy you are here. Please answer the following questions as honestly as you can.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you discover the Roots & Realms women's retreat?
What is calling you to this retreat and to the medicine of ayahuasca?
Have you sat with ayahuasca before? If yes, please describe your experience(s). When, where, around how many times?
Do you have prior experience with other plant/earth medicines or altered states of consciousness?
What are your intentions for this experience? What are you desiring to change, transform, evolve, and/or heal in your life, yourself, and your relationships?
What is your passion in life, your purpose, your calling?
Have you experienced traumas or hardships that have impacted your life significantly?
Do you have any health conditions?
*
Yes
No
Do you have a history of seizures, psychosis, bipolar disorder, or schizophrenia?
Please specify your health conditions if you have them, and any over the counter medications you are taking (especially SSRIS, MAOIs).
This retreat will take place in the beautiful Amazon rainforest, where we live immersed in nature and off grid. We do not have wifi, we use candles and flashlights at night, and our structures have mosquito net walls. Are you willing to live close to nature and to be off grid? Have you done so before?
This retreat you will get to meet, sit with, and interact with local Peruvians, and indigenous Shipibo, Quechua, and Machiguenga peoples. Do you have any experience relating with indigenous peoples?
Do you speak Spanish?
Yes
No
Entiendo y hablo un poco.
We offer a plant based diet on the retreat. Please specify if you have any dietary specifications or allergies.
If you are choosing to partake in a Master Plant Dieta ("diet"), it is important to follow the traditional restrictions one must practice while dieting a plant. Dieta restrictions include a simple diet with no salt, sugar, processed foods or oils, or red meat. You must abstain from sex and will stay by yourself in a tambo hut or treehouse for the duration of the 7 days. You will keep your energy to yourself, except I will check on you daily. Do you feel capable and willing to practice these restrictions?
Consent and Agreements
*
Is there anything else you would like to share?
Submit Application
Submit Application
Should be Empty: