Retreat registration · Ayahuasca Prajna

Name *

First

Last

E-mail *

Confirm Email

Age *

Country of residence / native language *

Upcoming dates

What is your intention for participating in a retreat? *

Describe what brings you to participate in this event? Be generous!

Are you suffering from a diagnosed disease, psychological condition (depression, anxiety, insomnia, bi-polar, obesity etc) or disability? *

Write "No" if doesn't apply

Are you currently undergoing any therapy course? *

With a psychotherapist or counsellor

What medication, if any, do you currently use and what for? *

Commercial of pharmaceutical name. Write "No" if doesn't apply.

Do you follow spiritual practices and or a religion? *

If yes, please describe

Have you used synthetic drugs before (recreationally or addiction)? *

If yes, please indicate which ones and when was the last time

Have you had experiences with natural psychedelics before (Ayahuasca, San Pedro, Peyote, Iboga, mushrooms etc)? *

If yes, please indicate which ones and when was the last time

What is your level of English

Additional questions or requests or if you have a food or other allergy or intolerance.

How did you find out about this retreat? *

Contact of reference, name of a friend

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