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

Contact Information

Emergency Contact

Health and Medical History

Psychological 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.


Additional Information

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.
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.