What is calling you to this work at this time?

Acknowledgment

Please confirm all three to continue.

Are you currently experiencing a major life challenge, recent loss, major transition, or emotionally difficult circumstance?

Please briefly explain

Have you previously worked with ayahuasca, other plant medicines, or psychedelics?

Have you ever experienced a challenging, overwhelming, or prolonged negative reaction?

Please briefly explain

Do you understand that ayahuasca experiences vary from person to person and that not everyone has visions?

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

Where should we send your response?

So we can arrange your discovery call, even if you don't finish today.

And your mobile number?

The discovery call is a phone call, so we'll need this to reach you.

Date of birth

For example, 03 21 1985

City / State

Who should we contact in an emergency?

Someone we can reach if we need to while you are with us.

Do you currently take any medications or supplements?

Prescription medications, over the counter medications, supplements, or herbal products.

A Yes here does not rule you out. It helps us prepare safely.

Please list the name, dosage, and frequency

Have you stopped taking any prescription medication within the past 90 days?

Please list the medication and approximately when you stopped

Have you ever been diagnosed with or experienced any of the following?

Check all that apply.

Within the past 12 months, have you experienced suicidal thoughts, a suicide attempt, or thoughts of harming yourself or someone else?

Please briefly explain

A yes response does not by itself determine acceptance and may require additional screening.

Do you have a history of seizures, epilepsy, or a significant neurological condition?

Do you have a heart or cardiovascular condition?

Including uncontrolled high blood pressure, abnormal heart rhythm, history of heart attack or stroke, coronary stent, pacemaker, or other significant cardiovascular condition.

Do you have a significant liver, kidney, or other medical condition we should know about?

Are you currently pregnant, breastfeeding, or is there a possibility you may be pregnant?

Please explain the condition, current treatment, and whether it is currently stable

You answered yes to a medical question above - a little detail here helps us hold you safely.

Do you have any allergies, dietary, mobility or accessibility needs?

Food or medication allergies, dietary restrictions, mobility needs, accessibility needs, or other physical support needs we should know about.

Please explain

Do you currently use any psychoactive substances?

Alcohol, cannabis/THC, nicotine, recreational drugs, or other psychoactive substances.

Please identify the substance, frequency of use, and most recent use

Are you willing to follow all preparation and safety instructions provided to you?

Including applicable medication and substance restrictions.

Please confirm the following

Please confirm all four to continue.

Cancellation and Rescheduling Policy

Nothing is paid today. A deposit is only taken if you go on to reserve a place on a ceremony weekend, and we will go through this policy with you on your free call. If our intake review finds ceremony is not right for you, any contribution you have made is returned in full. Please read the AyaWaken Church Cancellation and Rescheduling Policy, then confirm below.

How did you hear about AyaWaken?