Skip to content
Ayahuasca Retreat Haven
Home
Calendar
About
About Us
Ayahuasca
Spiritual Healing
Intensive Integration Circle
Breathwork
Spiritual Growth using Rapé
Help & Guide
What to expect
Cost
Schedule
Cancellation Policy
Frequently Asked Questions
Accommodations
Medical Guidelines
Covid 19
Items to Bring
Dieta Guide
Testimonials
Contact Us
Ayahuasca Retreat Haven
Navigation Menu
Navigation Menu
Home
Calendar
About
About Us
Ayahuasca
Spiritual Healing
Intensive Integration Circle
Breathwork
Spiritual Growth using Rapé
Help & Guide
What to expect
Cost
Schedule
Cancellation Policy
Frequently Asked Questions
Accommodations
Medical Guidelines
Covid 19
Items to Bring
Dieta Guide
Testimonials
Contact Us
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Numbers
Gender
*
Age
*
Emergency Contact Person
*
Emergency Contact's Phone
*
Dietary Preference
*
None
Pescatarian
Vegetarian
Vegan
Special Dietary Requirements/Food Allergies
Sleeping Arrangements
*
Single
Double
If you selected Double, with whom will you be sharing?
Do you have any experience with regards to plant medicine, or shamanic rituals or ceremonies?
Are you currently in therapy or any type of support group?
Do you have a past history of, or currently suffer from any of the following?
*
Cardiovascular disease, heart attacks, strokes/infarctions
High / low blood pressure
Mental illness, psychosis, schizophrenia, suicide attempts, behavioural disorders
Recent surgery
Past or recent physical injuries (incl. fractures or dislocations)
Recent or current infectious or communicable diseases
Tumours/Cancer
Epilepsy/Seizures
Diabetes
Asthma
Glaucoma or retinal detachment
Other health problems
Please provide details
Have you ever had any type of seizure?
Do you have any allergies?
Have you ever been hospitalized for medical reasons?
Are you currently pregnant or breastfeeding?
Yes
No
Have you ever taken SSRI or SNRI medication for depression or anxiety? Please provide details
Are you currently taking any medications? Please list
Please list any medications or vaccines you have taken over the past 12 months (prescribed or over the counter). Include dosage and frequency
Please list supplements (herbs, vitamins, etc) you have taken regularly in the past 12 months.
Have you ever used any type of psychoactive substance?
Alcohol
Marijuana/Hashish
Cocaine
Ecstasy
Crack/Amphetamines
Heroin/Morphine
Codeine
LSD/DMT
Ketamine
Other
Please indicate how many times you have used these substances, and when was the last time
Do you consider yourself addicted to one of these substances? Please elaborate
Have you had any incidents or accidents involving the use of these substances?
List any recreational substances that you have taken over the past 12 months (including alcohol and marijuana). Please include frequency of use
Anything else about your physical, emotional or mental status that you would like to share or that we should be aware of?
We know you did your research. Why did you choose to apply for a retreat the haven over other centers? *
*
I understand that a minimum 50% deposit is required to confirm my booking, or that I may pay the full retreat cost upon registration, if I prefer. I understand that my balance must be paid in full at least 3 weeks prior to the start of the retreat to guarantee my space. If I make a deposit with a credit card, the Haven will charge that card automatically for the outstanding balance 3 weeks prior to the start of my retreat.
*
Yes
I agree NOT to book flights or make travel plans until my registration has been approved. I understand that my registration is not confirmed until my application has been reviewed and approved by the Haven and I have paid my deposit.
*
Yes
Full refund only if you cancel registration 4 weeks prior to retreat start date
*
Yes
I accept the full terms and conditions, attest that all information is accurate and accept full legal & personal liability for joining this retreat, protecting the Haven from all legal liability.
*
Yes
Submit
error:
Content is protected !!