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Ayahuasca Ceremony Registration & Sacred Vetting Questionnaire


Welcome. We are honored that you are feeling called to sit with this sacred medicine. Because Ayahuasca is a powerful physical, emotional, and spiritual catalyst, we maintain a strict screening process to ensure the safety of the individual and the harmony of the entire group container.

Please complete this form with absolute honesty. All answers are 100% confidential and will only be reviewed by the lead organizers and facilitators.


Section 1: General Information


Birthday
Month
Day
Year

Section 2: Physical & Medical Screening (Critical Safety)

Ayahuasca can have severe, potentially life-threatening interactions with certain medications and medical conditions. Please answer carefully.


Are you currently taking any prescription medications, over-the-counter drugs, or supplements?
Do you currently take, or have you taken in the past 6 weeks, any of the following? (Check all that apply):
Do you have a history of any of the following medical conditions? (Check all that apply):
Are you currently pregnant, suspect you might be, or are you breastfeeding?

Psychological & Mental Health Screening

Do you have a personal history, or an immediate family history, of any of the following conditions?
Are you currently experiencing severe anxiety, panic attacks, or suicidal ideation?
Are you currently working with a therapist, psychiatrist, or counselor? [ ] Yes [ ] No

Experience & Intentions


Have you ever participated in an Ayahuasca ceremony before?
Do you have a personal support system or community in place to help you integrate your experience after the ceremony?

Sacred Agreements & Informed Consent


Please read and initial each point below to confirm your understanding and agreement:


Date
Month
Day
Year
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