Begin Your Intake

This application is the first act of preparation. Answer honestly and take your time - it takes about 15 minutes, and every application is read with care.

This application helps us care for you well. Ceremony asks for your honest participation, a willingness to prepare, and personal responsibility for your own path. Not everyone is a fit for this work, and not every season of life is the right one - your honest answers help us determine that together, with care.

Everything you share here is held in confidence and reviewed only by those responsible for your care.

Acknowledgment

Before you begin, we ask you to acknowledge three things: *

I understand this is not a quick fix and requires personal responsibility

I understand this is a spiritual practice, not a medical treatment

I agree to answer all questions honestly and completely

Your Details

Full name *

Date of birth *

Address *

Phone *

Email *

What is your current occupation? *

Which ceremony weekend are you interested in? *

Emergency Contact

Name *

Relationship *

Phone *

Your Intention

Why are you feeling called to ceremony? *

What are you hoping to receive or understand from this experience? *

Are you currently going through any major life challenges? If so, please explain. *

Readiness & Responsibility

Please select the statement that most accurately reflects your understanding of this work? *

This is not a quick-fix experience. Honest answers help us determine readiness.

I am looking for a quick solution to my problems

I understand this requires ongoing inner work

I am unsure but open to learning

Are you willing to follow all preparation guidelines and commit to the process? *

Yes

Are you open to facing difficult emotions or truths that may arise during ceremony? *

Yes

Unsure

Do you understand that ceremony is a spiritual practice held in prayer, and that every person's experience is different? (Not everyone has visions) *

Yes

Previous Experience

Have you attended ayahuasca ceremony or other traditional plant ceremonies before? *

Yes

If yes, please describe your experience(s).

If yes, please explain if you have had any challenging or overwhelming experiences in previous ceremonies?

Are you comfortable with the use of Mapacho (ceremonial tobacco) during ceremony for energetic cleansing and protection? *

Yes, I am comfortable with it

No, I prefer not to be around it

I’m not sure / I’d like to learn more

Medical & Health Information

Do you currently take any medications? *

Yes

If yes, please list all medications and dosages.

Have you ever been diagnosed with any of the following? *

Bipolar disorder

Schizophrenia or psychosis

Severe anxiety

Severe depression

PTSD

None

Do you have any history of seizures, epilepsy, or neurological conditions? *

Yes

Do you have any heart conditions or high blood pressure? *

Yes

Do you have any liver or kidney conditions? *

Yes

Are you currently handicapped or disabled? *

Yes

If yes, please specify

Do you have any allergies or dietary restrictions?(including food, medication, or environmental)? *

Yes

If yes, please specify

Are you currently pregnant or breastfeeding? *

Yes

If yes, please specify

Please list any additional medical conditions we should be aware of. *

Yes

If yes, please specify

Lifestyle & Habits

Do you currently use any of the following? *

Alcohol

Non-prescribed substances

Nicotine

THC

Are you willing to abstain from substances before and after ceremony as instructed? *

Yes

Support & Integration

Do you currently have a support system (friends, family, therapist, etc.)? *

Are you open to integration support after ceremony? *

Yes

Final Agreement

Please read and confirm each statement. *

I confirm that all information provided is accurate and complete

I understand ceremony is not suitable for everyone

I take full responsibility for my participation

I agree to follow all preparation and safety guidelines

I agree to the cancellation policy

Cancellation & Rescheduling Policy Agreement *

I have read and agree to the AyaWaken Church Cancellation & Rescheduling Policy. I understand that my deposit is non-refundable and non-transferable, and that no refunds or transfers will be issued within two weeks of my scheduled ceremony.

How did you hear about us? *

Begin Your Intake

Acknowledgment

Your Details

Emergency Contact

Your Intention

Readiness & Responsibility

Previous Experience

Medical & Health Information

Lifestyle & Habits

Support & Integration

Final Agreement

Cancellation & Rescheduling Policy Agreement *

Thank You - Your Application Has Been Received