Pre-Ceremony Intake Form IF THIS IS YOUR FIRST TIME SITTING WITH US:PLEASE FILL OUT THIS FORM. Name * First Name Last Name Email * Message * Date of Birth * MM DD YYYY Whatsapp number: * Country (###) ### #### What dates are you signing up for? * If this is your first Ayahuasca ceremony with us, please write a brief explanation of your motivation to participate in the ceremony. Also, please indicate if you have previous experience with Ayahuasca. * Who is recommending you/How did you find out about the ceremony? * Do you have any past experiences with Ayahuasca in a ceremonial context? * No, This would be my first time. 1 to 3 previous experiences. 4 to 10 previous experiences. More than 10 previous experiences. Are you taking any form of medication? If yes, please state its name, how long you have been taking it and what for. * Are you currently taking any supplements that affect serotonin and/or dopamine? * Do you have any pre-existing heart conditions? * Are you or have you ever been prone to seizures? * Do you have any pre-existing mental health issues? * Do you have any experience with mental/psycho-spiritual disciplines? i.e. Yoga, Meditation. * Do you have any questions, comments or concerns? Thank you! “It’s too late to be ready.” — ZEN MASTER DOGEN
