Application form

Our comprehensive screening questionnaire has been developed in partnership with the International Centre for Ethnobotanical Education, Research and Service (ICEERS). Please take your time to answer it as honestly and with as much detail as possible. This information will remain strictly confidential and will only be used to assess your suitability for a place on retreat with AYA Healing Retreats.

 

Please remember that the purpose of this screening questionnaire is to determine whether plant medicine healing is suitable for you…not whether you are suitable for plant medicine healing. Plant medicines are tools, like any other healing modality and like other tools for healing experiencing them entails certain risks. We need to make sure that our plant medicines will not compromise your wellbeing or harm you in any way before we allow you to begin your healing journey with us. In short, we care about your safety and we need to do what we can to ensure that during your time with us you are not at risk of harm. Plant medicines can be dangerous if the plants are not the right fit for the individual. Your answers to this questionnaire will help us to determine whether the plants we intend to use are going to help, rather than harm you.

Questionnaire

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PREFERRED DATES 2022

Participant information

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Gender. Please choose all that aply
Sexual orientation/expression. Please choose all that apply.

EMERGENCY CONTACT INFORMATION

Does this person know you will be in retreat with Plant Medicine?

Medical history and Sacred Plant use

Please note: The following section asks questions that may be sensitive in nature.
Please answer as accurately as possible. This knowledge is important to ensure your safety and the safety of others while on retreat

Are you currently pregnant?
Have you ever participated in an Ayahuasca ceremony?
Have you ever undergone a Master Plant Dieta?
Please highlight any physical health conditions that you are currently experiencing or have experienced in the past. Please choose all that apply.

Psychological information

It is important in order to ensure your safety whilst on retreat that we have full knowledge of any psychological health conditions you are currently experiencing or have done in the past. Please be as honest as possible when answering the following questions. You can be assured that your information will remain confidential and is used only to determine whether plant medicines are the right fit for you now.

Please highlight any psychological health conditions from the list below that you have either experienced in the past or are currently experiencing. Please choose all that apply.
Do you have a family history of any of the above psychiatric conditions?

Alcohol, addiction and other drugs use

Have you ever been diagnosed, treated, or self-identified with alcohol use disorder?
Have you ever experienced addiction to any other substances or activities (eg., work, sex, food, gambling) either in the past or present?

Alcohol, addiction and other drugs use

Are you allergic to any medication?
Are you currently taking or have you recently stopped taking anti-depressant medication?
Are you currently taking or have you recently stopped taking any other prescription medications?
Are you currently taking or have you recently stopped taking any natural supplements, herbal medicines, or vitamins?

Dietary requirements and allergies

Do you have any severe or potentially life-threatening allergies that would require the use of an Epi-Pen?
What is your diet preference?

Your intention

Additional information

Is there anything concerning your physical and psychological health history that has not been covered by this questionnaire that you would like to share with us?
Have you experienced what you would regard as a traumatic incident in your past that you would like us to know about?

Agreement and informed consent

I will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing.

I will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing.

I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca.

I have read, understand and will comply with the Metsa Noma medical guidelines (please refer to our Medical Guidelines page).

Thanks for submitting!