Plant Medicine Retreat in Ecuador Intake Form

Welcome to the initial step towards joining our transformative Plant Medicine Retreat in Ecuador. This journey is designed to foster deep healing and personal growth through the use of traditional plant medicines including Ayahuasca, San Pedro, and Psilocybin. To ensure the safety and well-being of all participants, we kindly request you to provide detailed information about your psychological and physical health. All information will be kept confidential and used solely to assess your suitability for the retreat.

Personal Information

Full Name: *

Date of Birth *

Gender: *

Contact Information

Phone Number *

Email Address: *

Emergency Contact

Name: *

Relationship: *

Phone Number: *

Health and Medical History

Please list any medical conditions you have been diagnosed with: *

Are you currently taking any medications? If yes, please list them: *

Specifically, are you taking any SSRIs (selective serotonin reuptake inhibitors) or any other psychiatric medications? Please provide details: *

Have you had any surgeries in the last five years? If yes, please specify: *

Do you have any allergies (medication, food, environmental)? Please list them: *

Psychological Well-being

Have you ever been diagnosed with a psychological or psychiatric condition (e.g., depression, anxiety, bipolar disorder)? Please provide details: *

Have you ever experienced a psychotic episode? If yes, please describe the circumstances: *

How would you describe your current emotional well-being? *

Experience with Plant Medicine

As part of our collaborative journey, we invite our partner practitioners to join the Haute Healing Oasis community as members. This initiative aims to deepen your connection with our services and enhance the authenticity of your recommendations to clients.

Have you previously participated in any plant medicine ceremonies (Ayahuasca, San Pedro, Psilocybin, etc.)? If yes, please describe your experiences: *

What are your intentions or goals for participating in this plant medicine retreat? Why do you want to come on this retreat? *

Do you have any concerns or fears about participating in plant medicine ceremonies? *

Lifestyle

How would you describe your current diet and lifestyle, specifically in terms of your physical activity level? *

Do you have any practices (e.g., meditation, yoga) that support your mental and emotional well-being? *

Additional Information

Is there anything else about your health or psychological state that we should be aware of? *

How did you hear about this retreat? *

Additional Comments

Consent and Acknowledgment

I understand that participating in plant medicine ceremonies can be physically and emotionally challenging. I affirm that the information provided in this form is true and accurate to the best of my knowledge. I consent to participate in the Plant Medicine Retreat in Ecuador, acknowledging the potential risks and benefits involved.

Signature (Type Name): *

Date: *

Thank you for taking the time to complete this intake form. Your honesty and openness are crucial to ensuring a safe and transformative experience for you and all participants. We will review your information and get in touch with you to discuss the next steps.