Request to Participate in a Santo Daime Work (Ceremony)
Please complete this form to submit your request to participate. Participation is reserved for individuals aged 18 and over. A member of our team will contact you for the next steps.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Day - Month - Year
Email
*
exemple@exemple.com
Telephone
*
Format: (000) 000-0000.
Have you ever taken ayahuasca?
*
Yes
No
Are you currently taking antidepressants?
*
Yes
No
Do you have :
*
a history of psychosis?
untreated bipolar disorder?
a recent hospitalization?
None of the above
If you answered yes to any of the questions above, please provide details (when, treatment, etc.):
*
What is your motivation or intention for participating? (2 to 3 lines maximum)
*
Were you referred by someone?
*
Yes
No
If yes, by whom? If not, how did you hear about our centre?
*
Send
Should be Empty: