Ayni Munay Ministry — Confidential Health Intake

Ayni Munay Ministry — Confidential Health Intake
Full Legal Name

First NameLast Name
Date of Birth

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Phone Number
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Email Address
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Emergency Contact - Full Name

First NameLast Name
Emergency Contact - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact

Have you participated in plant medicine ceremony before?
If yes, which medicines have you worked with?

AyahuascaIbogaIbogainePeyoteHuachuma/San PedroPsilocybin MushroomsBUFO/5 MEO DMT
Do you currently work with a therapist, counselor, or psychiatrist?
Do you have a regular spiritual or meditation practice? Please describe.
What is calling you to this ceremony at this time in your life?

Please answer Yes or No for each question. If yes, please provide details in the explanation field.
Do you have or have you had a heart condition, irregular heartbeat, or cardiovascular disease?
If yes, please explain: (optional)
Do you have high or low blood pressure?
If yes, please explain: (optional)
Do you have a history of seizures or epilepsy?
If yes, please explain: (optional)
Do you have liver disease or significant liver impairment?
If yes, please explain: (optional)
Do you have kidney disease?
If yes, please explain: (optional)
Do you have diabetes or blood sugar regulation issues?
If yes, please explain: (optional)
Do you have any respiratory conditions (e.g. asthma, COPD)?
If yes, please explain: (optional)
Do you have any autoimmune conditions?
If yes, please explain: (optional)
Do you have a history of cancer or are currently in treatment?
If yes, please explain: (optional)
Have you had surgery in the last 6 months?
If yes, please explain: (optional)
Do you have chronic pain conditions?
If yes, please explain: (optional)
Any other significant medical history we should know about?

These questions help us ensure ceremony is safe and appropriate for you. All responses are held in the strictest confidence and reviewed with compassion, not judgment.
Have you ever been diagnosed with psychosis, schizophrenia, or schizoaffective disorder?
If yes, please share any relevant context: (optional)
Have you ever been diagnosed with bipolar disorder (Type I or II)?
If yes, please share any relevant context: (optional)
Have you experienced manic or hypomanic episodes?
If yes, please share any relevant context: (optional)
Do you have a diagnosis or history of PTSD or significant trauma?
If yes, please share any relevant context: (optional)
Have you experienced dissociative episodes?
If yes, please share any relevant context: (optional)
Have you ever been diagnosed with borderline personality disorder?
If yes, please share any relevant context: (optional)
Have you ever experienced suicidal ideation or made a suicide attempt?
If yes, please share any relevant context: (optional)
Do you have a history of self-harm?
If yes, please share any relevant context: (optional)
Are you currently experiencing acute grief or significant recent loss?
If yes, please share any relevant context: (optional)
Is there anything about your mental health journey you would like the facilitation team to be aware of? (optional)

This section applies to women and those who may be pregnant. If not applicable, please select "Not applicable" for each question.
Are you currently pregnant or possibly pregnant?
Are you currently breastfeeding?
Are you currently taking hormonal medications? (birth control, HRT, etc.)
If yes, please specify the medication: (optional)
Any other women's health information relevant to your participation: (optional)*

This section helps us understand where you are in your life and how to best support your preparation and integration.
Are you aware of the dietary protocol (dieta) required before ceremony?
Do you have a support person or integration coach who is aware of your participation?
What is your primary intention for this retreat and ceremonies?
Is there anything else you would like the facilitation team to know before your ceremony? (optional)

Please read the following carefully before signing.
I confirm that all information provided in this form is accurate and complete to the best of my knowledge. I understand that withholding or misrepresenting medical or mental health information may affect my safety and the safety of others in ceremony. I consent to this information being reviewed by the facilitation team of Ayni Munay Ministry solely for the purpose of determining my readiness to participate. I understand this form is strictly confidential and will not be shared outside the Ministry.
Full Legal Name (typed signature)*
Today's Date:*

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By checking this box I confirm that all information provided is true and accurate to the best of my knowledge.*

Yes, I confirm and affirm
Ayni Munay Ministry · The Sacred Circle Fellowship · All responses are strictly confidential.
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All responses are confidential and reviewed only for your safety. We ask that you discontinue all recreational substances at least 14 days before ceremony.