Ayahuasca Foundation ten day retreat group picture

Ten Day Ayahuasca Retreat - $2950

December 5 - 14, 2027

- With Doña Angela

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Price

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$2,950.00 – (US)

Guests

People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

Participant Info

First Name *
Last Name *
Email *
Gender *
Gender *
Age *
Birth Date *
Phone
Address
Address 2
City
State/Prov.
Zip/Postal
Country
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
Do you have any current or past medical conditions?	NO YES examples: high blood pressure, heart conditions, diabetes, epilepsy, asthma, etc.
If YES, list any and all health or medical conditions
If YES, please provide details	condition, severity, treatment, and current status
Do you have any heart problems or a heart condition?	It is very important that we know about any heart issues so please inform us if there are.
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
List any surgeries or procedures you have had
How would you rate your physical fitness level?	Sedentary (little to no regular exercise) Moderately active (occasional exercise or light activity) Active (regular exercise, comfortable with moderate physical demands) Very active (frequent intense exercise, comfortable with high physical demands) Programs involve some hiking, frequent walking, and spending time in hot, humid conditions
Please provide details about your physical health	types of activities you do, frequency, and any limitations
Have you ever experienced heat-related illnesses?	NO YES heat exhaustion, heat stroke, etc.
If YES, please provide details about any heat related issues
Have you ever been diagnosed with a mental health condition? *	NO YES depression, anxiety, bipolar disorder, schizophrenia, psychotic disorders, etc.
If YES, please provide details about your mental health	diagnosis, treatment history, current status, and any hospitalizations
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
Have you ever experienced suicidal thoughts or behaviors?	NO YES, in the past YES, currently
If YES, please provide more information	when, frequency, and any professional support received
How would you describe your current emotional resilience?	Very resilient (I handle stress and challenges well) Moderately resilient (I manage most challenges but may need support) Somewhat resilient (I often struggle with stress or intense emotions) Not resilient (I find stress and challenges overwhelming) ability to handle stress, adapt to challenges, or process intense emotions
Please provide an example of a challenging situation and how you handled it
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.
Are you currently taking any medications, supplements, or herbal remedies? *	NO YES Ayahuasca can interact negatively with certain medications
If YES, please list all medications, supplements, etc. and reasons for use	medications/supplements, dosages, and reasons for use
Did you receive a Covid Vaccine?
If YES, which vaccine, how many, and when was your last shot?
Do you have any allergies?	NO YES food, environmental, insect bites, etc.
If YES, please provide details about allergies

Experience

Have you ever participated in an ayahuasca ceremony?	NO YES
If YES, please tell us more about those experiences	Number of ceremonies attended, most recent ceremony, where and with whom
Describe a significant experience or insight from a ceremony
Have you worked with other plant medicines or psychedelics?	NO YES psilocybin, San Pedro, iboga, peyote, kambo, bufo, LSD, etc.
If YES, please provide more details	Substances used, most recent experience, context, key takeaways or challenges
Have you ever participated in a plant dieta?	NO YES
If YES, please provide details	type of dieta, duration, plants used, and key experiences

Personality

How comfortable are you spending extended time in nature?	Very comfortable (I thrive in nature and have significant experience) Moderately comfortable (I enjoy nature but have limited experience) Somewhat comfortable (I’m open but may find it challenging) Not comfortable (I prefer urban or controlled environments) living in a jungle environment with limited modern amenities
How would you describe your ability to follow instructions, especially in unfamiliar or challenging settings?	Excellent (I follow instructions carefully and ask for clarification when needed) Good (I generally follow instructions but may need reminders) Fair (I sometimes struggle to follow instructions) Poor (I prefer to do things my own way)
How open are you to being taught new perspectives or practices that may differ from your current beliefs?	Very open (I’m eager to learn and adapt) Moderately open (I’m open but may need time to process new ideas) Somewhat open (I’m cautious about new perspectives) Not very open (I prefer to stick with what I know)
How do you typically interact in group settings?	Collaborative (I enjoy working with others and value everyone’s input) Independent (I prefer working alone but can collaborate when needed) Dominant (I often take the lead and guide group dynamics) Reserved (I tend to stay quiet and observe)
How do you handle conflict or disagreements with others?	I address conflicts calmly and seek resolution through communication I try to avoid conflict but will engage if necessary I tend to get defensive or upset during conflicts I struggle to manage conflicts and may become confrontational
Are there any behaviors or tendencies you’re aware of that might challenge group harmony?	difficulty sharing space, strong need for control, or emotional reactivity

Motivation

What else should we know about you?
How did you hear about us?

Email newsletter	Please send me the email newsletter
I understand that ayahuasca is a powerful plant medicine and that full transparency about my health and experience is essential for my safety and the safety of others. *	NO YES
I confirm that all information provided in this application is accurate and complete to the best of my knowledge. *	NO YES
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
There will be no additional charges for this retreat.

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Ten Day Ayahuasca Retreat - $2950

Price

People in your group

Participant Info

Experience

Personality

Motivation

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