Admission Form · Plant Medicine Retreat

Flower of Life Ayahuasca Healing Center — Please complete this confidential intake form so our team can evaluate your admission and care for your safety.

All information you share is kept strictly confidential and is used only to evaluate your admission, protect your wellbeing, and organize your participation. Please answer honestly and completely — there are no wrong answers, only information that helps us keep you safe.

i Retreat Information

Please complete all required fields and sign before submitting.

1 Personal Information

2 Emergency Contact

Does this person know that you will be attending the retreat? *

3 General Health Information

How would you describe your current health condition? *
Do you have any diagnosed medical condition? *
Have you had any major surgery? *
Have you been hospitalized in the last 12 months? *
Do you have a history of any of the following conditions? (Select all that apply)

4 Current Medications, Supplements & Treatments

Are you currently taking any prescribed medications? *
MedicationDoseFrequencyReason
Are you taking antidepressants, anti-anxiety medication, mood stabilizers, or antipsychotics? *
Are you taking medication for blood pressure, heart conditions, or circulation? *
Are you taking supplements, medicinal plants, vitamins, or natural products? *
Have you recently stopped taking any medication? *

5 Mental & Emotional Health

Have you received any psychological or psychiatric diagnosis? *
Have you experienced episodes of severe depression, intense anxiety, or panic attacks? *
Do you have a history of psychosis, schizophrenia, bipolar disorder, or manic episodes? *
Have you experienced suicidal thoughts or self-harm? *
Are you currently receiving psychological therapy or psychiatric support? *

6 Substance Use

Do you consume alcohol? *
Do you consume cannabis? *
Do you use any other psychoactive substances? *
Have you experienced substance dependence or problematic substance use? *
Are you willing to abstain from alcohol, recreational drugs, and other unauthorized substances before, during, and after the retreat, according to the team's instructions? *

7 Allergies, Diet & Restrictions

Do you have any food, medication, or environmental allergies? *
Do you follow a specific diet? (Select all that apply)
Do you have any religious, ethical, or cultural restrictions related to food? *
Do you have a history of eating disorders? *

8 Pregnancy, Breastfeeding & Reproductive Health

Are you pregnant or is there a possibility that you may be pregnant? *
Are you currently breastfeeding? *
Do you have any relevant gynecological, hormonal, or reproductive condition? *

9 Previous Experience with Plant Medicine or Retreats

Have you previously participated in plant medicine retreats? *
Have you had difficult experiences, adverse reactions, or previous complications? *
Have you previously worked with practices such as meditation, breathwork, fasting, sweat lodge, plant diets, or other ceremonies? *

10 Personal Motivation & Intention

Do you have a support network for after the retreat? *

11 Conditions of Participation

Please read and check each statement to confirm your understanding and acceptance. All are required.

I declare that I have been informed that a plant medicine retreat may involve risks, including but not limited to:

  • Physical reactions such as nausea, vomiting, diarrhea, dizziness, fatigue, sleep disturbances, or changes in blood pressure.
  • Emotional reactions such as anxiety, sadness, fear, emotional release, or intense memories.
  • Psychological reactions such as confusion, temporary disorientation, or difficult inner experiences.
  • Possible interactions with medications, supplements, substances, or pre-existing medical conditions.
  • The need for post-retreat integration through rest, therapeutic support, or community support.

I confirm that I have had the opportunity to ask questions and that I will participate freely and voluntarily.

13 Authorization for Emergency Care

In the event of a medical or psychological emergency, I authorize the organizing team to contact my emergency contact and, if necessary, request external medical care.

14 Data Protection & Confidentiality

I authorize the organizing team to collect and review the information in this form solely to evaluate my admission, protect my safety, and properly organize my participation.

✓ Signature

I, [your name will appear here], confirm that the information provided in this admission form is true and complete, and that my signature below applies to my declarations of conditions of participation, informed consent, authorization for emergency care, and data protection above.

Use your finger, mouse, or stylus to sign above
✓

Admission form received

Thank you, friend. Your confidential admission form has been securely submitted.

A PDF copy has been sent to your email address. Please keep it in a safe place.

Our team at Flower of Life Peru will review your information and be in touch shortly regarding the next steps for your retreat.