Name
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First Name
Last Name
Preferred Pronouns
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Email
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Phone
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Country
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Age
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Birth Date
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MM
DD
YYYY
Emergency Contact Name
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First Name
Last Name
Emergency Contact Relationship
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Emergency Contact Phone Number
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Country
(###)
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Emergency Contact Email
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What are your intentions for coming on this journey? What is your motivation? What do you hope to get out of the trip?
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This is an important part of the application. Take your time to share your story with us and let us know why you are hearing the call to join us in Peru. Please write at least a couple of thoughtful paragraphs. If we receive a short answer, there is a chance we may not respond to your application. Thank you for your understanding.
Are you currently working with a therapist, coach, and/or other practitioner?
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How long have you been seeing them and how often?
Previous Experience
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Have you previously participated in any entheogenic plant medicine ceremonies? Specifically, with Ayahuasca & San Pedro (Wachuma)? Please share any details and takeaways regarding your experience.
Medical Conditions
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Please inform us of any physical medical conditions you have had in the past or are presently dealing with. Please list any serious injuries or surgeries.
Psychiatric Illness History
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Have you ever been diagnosed with a psychiatric illnesses? If so, with what diagnosis? Is there a history of psychiatric illness in your family? Please inform us of any past or current conditions of depression, anxiety or other psychological diagnosed conditions.
Suicidal Ideation & Attempts
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Have you had recent thoughts of suicide? If yes, when and how long did the suicidal ideation last?
Have you ever attempted suicide? If so, when was the last time?
Medications
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Please list any natural supplements, prescription and/or over the counter medications you are currently taking. Please indicate the dosage amounts for each medication and length of time you have been taking them.
Allergies and/or Food Preferences
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Please list any allergies to medications, food, or environmental substances. Include any dietary requirements or preferences you may have.
Substance Abuse
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Please inform us of any substance abuse issues or addictions you currently have. How long have you had these particular addictions or issues? Please be specific here.
High Altitude Concerns
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If you have any health issues that concerns regarding your ability to be at high altitudes for an extended period of time, please let us know.
Room/Price Preference
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$3,300 - Shared Double, Private Bath
$3,700 - Private Room, Private Bath
Zoom Interview Availability
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We require participants to meet with us on Zoom before being accepted into the retreat. Please share a few preferred meeting days and times (including time zone) so that we can schedule an interview following the receipt of your application.
How did you hear about us?
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Additional Comments
If you have any other comments or questions, please let us know!
Reading Commitment
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Liability Waiver
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