Four Week Ayahuasca Healing Empowerment Course

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$5,550.00 – (US)

2 Participant Info

First Name *
Last Name *
Email *
Gender *
Birth Date *
Phone
Address
Address 2
City
State/Prov.
Zip/Postal
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Passport Number	We must report all program participants to the National Reserve and they request this information.
Emergency Contact Info	Name and phone number
Dietary restrictions
Diet Details	Special considerations or anything else you'd like to mention regarding your diet
Physical Health	CHECK ANY AND ALL THAT APPLY: Low Blood Pressure High Blood Pressure Heart Disease or Problems Heart Surgery Heart Attack Irregular Heartbeat Chest Pain Circulation Problems Diabetes Meningitis Migraines Epilepsy Hyperthyroidism Hypothyroidism Cancer or Tumor Surgical Procedures HIV/AIDS Asthma Ulcer Obesity Chronic Pain Fibromyalgia Arthritis Aneurysm Stroke Head Injury Neurological Disease Infectious Disease Gynaecological Condition Other (please specify)
Physical Health Details	If you want to provide more detailed information
Psychological Health	CHECK ANY CONDITIONS BELOW that you are currently experiencing: Schizophrenia Depression Paranoia Panic attacks Obsessive Compulsive Disorder Suicidal Thoughts Post-Traumatic Stress Disorder Psychosis Bipolar Disorder Eating Disorder Chronic Anxiety Autism Asperger’s Borderline Personality Disorder Depersonalisation Disorder Multiple Personality Disorder Self-Harm Other, please specify
Psychological Health Details	If you want to provide more detailed information
How would you currently describe your overall state of health?	Write "healthy" if you have no issues
Medication you are currently taking	Pharmaceutical, natural, vitamins, supplements, etc.
Special Skills/Talents
Hobbies
What has been your experience with psychedelics?	Ayahuasca, DMT, mushrooms, LSD, san pedro, peyote, mescaline, ecstasy, etc.
What drugs have you taken and what do you currently use?
Describe your religious/spiritual views
Describe a profound spiritual experience you've had
Do you currently practice a discipline of some form?	yoga, meditation, qi gong, martial arts, sun gazing, etc.
List the most influential books you have read
List your favorite musicians
Do you play an instrument?	What instrument(s)? For how long?
How do you feel about singing?	NOTE: Singing healing songs (icaros) is central to this tradition
Describe your physical fitness
Describe your experience with hiking/camping
Why do you want to do this course?
What do you feel you'll contribute to the course?
What will be your greatest obstacle during the course?
Describe what you fear most
How would you rate the quantity and quality of love in your life?
What is your dream for the future?
What do you hope to achieve by attending this course?
Will you be sharing a room? With whom?	Please provide the name of the person who will share a room with you, or just answer 'no'
What else should we know about you?
How did you hear about us?
Email newsletter	Please send me the email newsletter
Terms and Conditions *	I accept the terms and conditions.click to read the Terms and Conditions
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

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Payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products
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Four Week Ayahuasca Healing Empowerment Course - $5550

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2 Participant Info

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4 Payment