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.

Preferred Dates

OtherMay. 20-31, 2019 (Ayahuasca & Noya Rao Silent Retreat)Jun. 17-28, 2019 (Ayahuasca Healing & Master Plant Dieta)Jul. 1-12, 2019 (Healing Trauma: Somatic Expiriencing & Ayahuasca Retreat)Oct. 7-18, 2019 (Ayahuasca & Noya Rao Silent Retreat)Oct. 27- Nov. 7, 2019 (Master Plant Dieta with Papa G.)Nov. 18-29, 2019 (Noya Rao Voice of Light)Dec. 2-13, 2019 (Ayahuasca Healing & Master Plant Dieta)Dec. 16-27, 2019 (Ayahuasca Healing & Master Plant Dieta)

Discount Code

Participant Information

Emergency Contact Information

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?

If you answered yes, please provide details below of the ceremony(s) including the date(s), location(s) and a summary of your experience(s) of the sacred medicine.

Have you ever undergone a Master Plant Dieta?

If you answered yes, please provide details below of the dieta(s) including the date(s), location(s) and a summary of your experience(s).

Please highlight any physical health conditions that you are currently experiencing or have experienced in the past. Please choose all that apply.

How would you describe your current state of health?

Have you ever undergone major surgery (requiring a general anaesthetic)?

If so, please provide details of the surgery including the ailment, date of operation and any limitations that you are now bound by.

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.

Are you currently taking or have you ever been prescribed any medications for these condition(s)?

Do you have a family history of any of the above psychiatric conditions?

If so please specify which family member(s), which condition(s) and the current state of health of those family members.

Alcohol, Addiction and Other Drug Use

Have you ever been diagnosed, treated, or self-identified with alcohol use disorder?

If so, please provide us with some additional information about your experience including the date (s) or time span of your addiction and whether you have undergone any therapy or rehabilitation to heal.

Have you ever been diagnosed, treated, or self-identified with drug addiction?

If so, please provide us with some additional information about the types of drugs, date(s), or time span of addiction and your experience of any therapy or rehabilitation you have undergone to heal.

Have you ever experienced addiction to any other substances or activities (eg., work, sex, food, gambling) either in the past or present?

If so can please tell us more about your experience.

Medication and Natural Medicine Use

Are you allergic to any medication?

If yes, please specify which medication (s)

Are you currently taking or have you recently stopped taking anti-depressant medication?

If yes, please specify which medication(s)

Are you currently taking or have you recently stopped taking any other prescription medications?

If yes, please specify which medication (s)

Are you currently taking or have you recently stopped taking any natural supplements, herbal medicines, or vitamins?

If yes, please specify which supplement (s)

Dietary Requirements and Allergies

Do you have any allergies to specific foods?

If yes, please specify which foods and the reaction that results when you ingest the food.

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

If yes, please specify.

What is your diet preference?

Your Intention

Please share your intention for wanting to participate in our sacred medicine retreat.
If you have not done so, please take some time to reflect deeply on this question. It is very important for us (and you) to clarify what you hope to achieve by attending our retreat both for your own healing and for us to determine the specifics of your Master Plant Dieta.

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?

If yes, please provide details below

Have you experienced what you would regard as a traumatic incident in your past that you would like us to know about?

If yes, please provide any additional information below that you feel may be helpful for us in supporting you whilst on retreat.

Please describe your current living and work situation; please note if you are studying or working, your profession and describe the home environment that you will be returning to after your time with us. This information is important so as we can do our best to prepare you for returning to your home life after your sacred medicine journey with us.

Would you like to organise a Skype meeting with a staff member of AYA Healing Retreats prior to the commencement of the retreat?

Please indicate three suitable dates and times and your time zone.

Agreement and Informed Consent

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

I will discontinue all use of alcohol, marijuana, recreational, street drugs and non-prescribed pharmaceuticals at least 3 weeks prior to commencing with AYA Healing Retreats. I understand that many street and recreational drugs are strongly contraindicated with Ayahuasca and can be very dangerous and potentially fatal when combined.

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 AYA Healing Retreats medical guidelines and safety policy.

Ready to journey with us?

Ask us questions about what to expect on retreat, book a free Skype session with us, start you medical screening questionnaire and get set to be profoundly changed.

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