AYAHUASCA HEALING RETREAT AND AMAZON JUNGLE SAFARI First Name*Last Name*Date of Birth*Age*Gender Male Female Other PreferenceEmail*Phone*Where do you currently live? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How did you hear about us?Emergency Contact:*Ceremony QuestionsHave you experienced Ayahuasca before?* Yes NoI UNDERSTAND I WILL BE FOLLOWING DIETARY RESTRICTIONS AND REQUIREMENTS: (See attached diet requirement page)* Yes NoAre you willing to commit to the preparation diet? No salt, sugar, spices, dairy, oil, fermented fruits, herbs, prescriptions, caffeine, pork, red meat, processed food, sex of any kind including masturbation, and social media or media consumption?* Yes NoPlease share your healing intentions and why you are interested in working with plant medicinesHave you had any experience with visionary plant medicines, or psychedelics? Please explainHave you experienced adverse or particularly difficult experiences with other psychoactive substances that you have found hard to integrate? Please explainMedical QuestionsThe following questions may be painful for you. Please note that all information given is kept strictly confidential. It is not our intention to relive any traumas/pain you may have lingering or affecting you, but it helps us understand what self-healing modalities we can undertake or prepare for you.We also ask these questions because you'll be working in a group, usually with strangers, during our retreats and courses. We want to ensure a safe, healing space for all participants involved.If you do not feel comfortable describing the associated medical detail, please write how you feel. If you'd prefer to only discuss it over the phone or Skype during our follow-up, then please note that in the details field. Thank you so much for your honesty and understanding. ♥Are you pregnant or think that might be pregnant?* Yes NoHave you been hospitalized in the last 20 years?* Yes NoIf YES please explainDo you have any dietary restrictions? This includes allergies, vegan/vegetarian, or gluten free* Yes NoIf YES, please explain your dietary restrictions in detail.Do you have any specific fears, reactions, allergies, or aversions that we need to be aware of?Are you currently or have you ever received therapy, attended a support group, and/or worked with a counsellor, psychiatrist, psychologist or psychotherapist?* Yes NoIf YES, please explain including type, duration and quality of your experienceIf YES, did you receive a Psychiatric diagnosis? Please explainHave you ever had any suicidal thoughts, or have you attempted suicide?* Yes NoIf YES, please explain including how recently you've experienced this and whether you have attemptedIs there anyone in your family with a history of psychiatric disorders?* Yes NoIf YES, please explain your family's historyHave you experienced traumas in your life? This includes traumatic events as well as ongoing traumatic experiences* Yes NoIf YES, has this influenced your desire to attend this retreat?Do you suffer from or have a family history of any of these ailments?* Cardiovascular disease, including heart attack Psychiatric Condition Recent Operation Infections or Contagious Diseases Epilepsy Asthma (if yes, please bring your inhaler to the retreat) None of theseDo you suffer from high blood pressure?* Yes NoAre you currently taking an anti-depressant medication such as a SSRI?* Yes NoAre you taking antidepressants such as MAO inhibitors?* Yes NoHave you in the past or currently suffer from seizures?* Yes NoDo you drink alcohol?* Yes NoIf YES, are you willing to fully detox off any alcoholic substances a minimum of 7 days prior to your retreat?* Yes NoDo you smoke?* Yes NoDo you use any "illegal" substances?* Yes NoIf YES, are you willing to fully detox off any substances a minimum of 7 days prior to your retreat?* Yes No, it's an addiction, and may be a challengeAre you taking ANY western medical prescriptions, over-the-counter, or alternative, homeopathic medications or taking herbal supplements? If so, please list and explain (Please note: we have a very extensive list of medications that conflict/counteract with the vine. For your safety, please provide us with an accurate list and we can discuss possible options available)Is there anything else we should know about your physical or mental state?Do you, or have you practiced martial arts, boxing, or any violent contact sport?General QuestionsPlease be aware that we share this magical place filled with indigenous species of flora and fauna who call the jungle 'home.' We do everything in our power to love and respect all living beings. We ask that you respect everything by admiring their uniqueness and beauty from a distance. Please do not touch unless otherwise guided/instructed to do so.How do you feel about the rustic aspects of Spiritual Dimensions Healing Centre?* Great! I'm excited and I can't wait to experience it! Not so excited.Are you able to hike, 3+ Kilometres over uneven ground?* Yes, I DO NOT need any assistance No, I NEED assistance or long breaks to cover that distancePlease share with us anything else we need to know that would make your stay more comfortable(Please be as specific as possible. This information is very helpful for our Shamans) Is there anything else you would like us to know about yourself?Why is the Ayahuasca Diet and Preparation so important?This diet is crucial to prepare your physical body for the Ayahuasca journey and to allow for full integration of the plant medicine. When we are occupied with and distracted by impure foods or activities, it makes it more difficult to focus on the Medicine. It can also make ceremonies much more challenging when one has to purge more than necessary because of dietary or lifestyle choices.Adhering to the diet is a test of discipline and displays respect for and commitment to the spirit of Mother Ayahuasca. This type of diet is a common, time-honoured tradition among Ayahuasca practitioners and shamans across the Peruvian Upper Amazon.Dietary RestrictionsWe recommend that guests begin their diet at least seven days prior to drinking Ayahuasca. A minimum of 5 days before or after is recommended if 7 days isn’t doable. On one level, the diet involves shifts in the food that we digest, but equally important are the changes in what we ingest mentally and energetically. Incorporation of solitude and minimal talking and the elimination of idle chitchat are very important. For those living in modern countries, the diet also involves abstinence from television, radio, mass media, and any other activities that alter perception without your participation.Restrictions Include:• No salts (e.g. table salt, soya sauce, fish sauce, etc.) • No sugar or artificial sweeteners (Stevia, aspartame, agave, etc.) • No pork/red meat (for fourteen days before and after a ceremony) • No caffeine • No animal fat (lard, etc.) • No dairy products (milk, cheese, yogurt) • No oil (except coconut/olive oil very sparingly) • No hot spices/ chilies/ pepper • No ice cold or carbonated drinks • No dried fruits • No vinegar or pickled foods • No spinach • No yeast or yeast extracts • No fermented foods (kimchi) • No alcohol • No recreational or prescription drugs (anti-depressants, benzos, marijuana, mushrooms, ecstasy, cocaine, LSD, etc.) • No fluoride toothpaste • No sexual activity of any kind including masturbation, kissing, and raising kundalini energy. • No discordant music, reading or movies • You also want to avoid synthetic soaps, perfumes, toiletries, etc.