Ten Day Women’s Ayahuasca Retreat

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1 Price

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$3,450.00 – (US)

2 Participant Info

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First Name *
Last Name *
Email *
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

3 Health

Do you have any current or past medical conditions?	NO YES examples: high blood pressure, heart conditions, diabetes, epilepsy, asthma, etc.
If YES, please provide details	condition, severity, treatment, and current status
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
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	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
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	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 details	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
Are you currently taking any medications, supplements, or herbal remedies?	NO YES Ayahuasca can interact negatively with certain medications
If YES, please provide details	medications/supplements, dosages, and reasons for use
Do you have any allergies?	NO YES food, environmental, insect bites, etc.
If YES, please provide details
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?

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
Terms and Conditions *	I accept the terms and conditions.click to read the Terms and Conditions
Confirm you are real *	Type the letters and numbers you see above to verify that you are actually a person.
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 Women's Ayahuasca Retreat - $3450

Ten Day Women’s Ayahuasca Retreat – $3450

1 Price

2 Participant Info

3 Health

5 Security Check

6 Payment

Ten Day Women's Ayahuasca Retreat - $3450

Ten Day Women’s Ayahuasca Retreat – $3450

1 Price

2 Participant Info

3 Health

4 Consent

5 Security Check

6 Payment