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About
Yachats
Events
Resources
Participant Intake Form
Legal Name
Preferred Name (if different)
Email
Mobile Number
Alternate Number
Address
Emergency Contact Name
Emergency Contact Number
Emergency Contact Relationship
I was referred by:
Have you ever attended an Ayahuasca ceremony before?
Yes
No
Have you ever attended a ceremony with us before?
Yes
No
Please briefly state your reasons for seeking to attend a ceremony with us:
What are your current life challenges?
Are there any trauma triggers that you would like us to be aware of (ex: touching, oud noises, close spaces, shouting, drumming, high pitched noise, smoke)
What would you like to gain from this experience?
What is your occupation?
What are your hobbies or interests?
Who are the most important people in your support network (friends, family, spiritual leaders/community, therapists, etc.)
Is there anywhere your support network is lacking?
Are you serving or have you ever served in any branch of the armed forces of the United States?
Yes
No
Do you have experience with martial arts?
Yes
No
Are you a first responder (highway patrol, EMT, paramedic, etc.)
Yes
No
Have you experienced any of the following: Meditation, consciousness altering states, or shamanic retreats before?
Yes
No
If yes, please explain:
Have you experienced trauma in childhood?
Have you experienced trauma in adulthood?
Have you experienced significant losses or grief?
Does your immediate family support you having this experience?
Allergies?
Conditions requiring special consideration (medical/physical):
Are you currently pregnant?
Yes
No
Do you have a diagnosis of a terminal medical condition?
Yes
No
Have you ever been hospitalized for any psychiatric or emotional issue?
Yes
No
Have you ever had substance abuse issues?
Yes
No
Do you take any MAO inhibitors? (Marplan, Nardil, Niamid, Parnate, Jatrosom, Emsam for example):
Yes
No
Do you use any SSRIs (Zoloft, Celexa, Lexapro, Luvox, Paxil, Prozac, Vibryd or Sumbyax)?
Yes
No
Do you take any tricyclic antidepressants? (Anafranil, Tofranil, Vivactil, Nortriptyline, Amitriptyline, Imiprex or Amoxapine for example)
Yes
No
Do you use an asthma inhaler or take asthma medication
Yes
No
Do you use any amphetamines? (Adderall, Ritalin, Concerta & Vyvanse for example)
Yes
No
Do you take any narcotic pain killers? (Oxycodone, Vicodin, Codeine, Dilaudid, Duragesic/Fentanyl, Demerol, Norco, Lorcet, Methodone or Heroine)
Yes
No
I am over the age of 21:
Yes
No
I do not have a history of psychosis and/or schizophrenia.
Yes
No
I have not been diagnosed with a personality disorder.
Yes
No
I do not have an active medicated diagnosis of bipolar disorder.
Yes
No
I do not have a history of seizures or a diagnosis of epilepsy.
Yes
No
I am not currently experiencing anorexia and/or bulimia .
Yes
No
I have not experienced a stroke or embolism.
Yes
No
I do not have severe asthma or emphysema.
Yes
No
I do not have a known cardiac illness (previous heart attack or stroke, pericardia, heart murmur, etc.)
Yes
No
I do not have severe uncontrolled high blood pressure.
Yes
No
I do not have Crohn’s disease, irritable bowel syndrome, ulcerative colitis, or intestinal ulcers.
Yes
No
I have not had surgery within the last three months on any part of my digestive system.
Yes
No
I do not currently have any liver disease or impaired liver function.
Yes
No
Accuracy Agreement
By checking this box you affirm that your answers are correct and accurate to the best of your knowledge.
Accuracy Agreement
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