Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
Which Retreat are you applying for? (Location & Dates)
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
Country
(###)
###
####
Referred by
*
First Name
Last Name
Gender Identity & Preferred Pronouns
*
Tell us a bit about your spiritual, healing, and transformation journey.
*
Please list any areas where you feel stuck, blocked, or limited (emotionally, physically, spiritually, mentally, or in life).
*
What are your intentions for the retreat?
*
Have you worked with Shamanic traditions previously?
*
If yes, please describe. If not, write 'no'.
Do you work with a primary spiritual teacher or a specific spiritual tradition or lineage?
*
If yes, please describe. If not, write 'no'.
Any Medical Conditions
*
List any medical conditions you have, and any medications or treatments you are engaged in to manage the conditions.
Of special note: heart conditions, blood pressure issues, diabetes, epilepsy, asthma, and other conditions may be contraindicated for this practice.
Write N/A if not applicable
Please list any past or current medical conditions or hospitalizations:
*
Please explain the condition, illness, or accident and results of treatment. Write N/A if not applicable.
Please describe your mental health history.
*
Have you ever been diagnosed with a personality disorder, schizoaffective disorder, bipolar disorder, or any other mental health conditions?
Please include substance abuse, addiction, eating disorders, PTSD, major trauma, specific diagnoses, and/or symptoms, if relevant (and whether current or past).
If so, please describe.
Are you receiving support, therapy, and/or treatments or any of the above?
Write N/A if not applicable.
Mental Health Symptoms
*
Have you experienced Anxiety, Depression, Self harm, Intrusive thoughts or Suicide Ideation in the last 6 months?
If you have experienced any of the above, are you currently receiving treatment? Please explain.
Write N/A if not applicable.
Current Grief
*
In the past 6 months, have you experienced extraordinary grief due to a break-up, a loss, or the death of a loved person or animal?
Are you receiving support, therapy, medications, and/or treatments for this experience?
Please explain.
Write N/A if not applicable.
Recent Traumatic Experiences
*
Have you experienced physical, emotional, or psychological trauma in the past year? If so, please give a short description of what the traumatic experience involved, time frame, and approximate date. Also, your current relationship to the trauma.
Write N/A if not applicable.
Do you have a family history of severe mental illness (bi-polar, schizophrenia, DID, depersonalization)?
*
Please describe and include your family member's relationship to you (i.e. mother, brother, grandmother, etc). Write N/A if none.
Are you taking any medications currently?
*
If so, please list and include what they are for. If not write N/A.
Have you taken any medications in the last three months?
*
If so, please list and include what they were for as well as date last taken. If none, write N/A.
Please list any supplements you are currently taking or which you have taken in the last three months.
*
(Be aware that protein powders may contain L-Tyrosine, which is contraindicated with the plant sacraments that are used in our ceremonies.)
Please include date last taken. If none, write N/A.
What is your experience with altered states if any?
*
Please describe and include approximate dates and frequency as well as general experience (good, bad, fair), and any particularly good or bad experience. Or anything else you think we should know. If none, write N/A.
Plant Medicine Ceremonies + Consent
*
Please note that certain drugs and medications have been found not to be compatible with the Amazonian plant medicine optionally offered at this retreat.
It is important that you know the following information so that you can be educated regarding contraindications in your decision as to whether or not to participate in these ceremonies.
It is NOT safe to work with this plant medicine if you take any of the following drugs or medications.
-Any medication that contains Monoamine Oxidase Inhibitors (MAOI's)
-SSRI's (any Selective Serotonin Reuptake Inhibitor)
-SNRI's (Serotonin-Norepinephrine Reuptake Inhibitors)
-Antihypertensives (high blood pressure medication)
-Appetite suppressants (diet pills)
-Medicine for asthma, bronchitis, or other breathing problems; antihistamines, medicines for colds, sinus problems, hay fever, or allergies
-CNS (Central Nervous System) depressants
-Antipsychotics
-Barbituates
-Any Illicit Drugs
We do suggest a minimum one week abstinence from alcohol and/or marijuana in preparation for ceremonies as well.
It is essential to stop taking the above substances, and give your system sufficient time to remove them from the body (a minimum of 3 months), before you begin our retreat:
Please consult your doctor for guidance on a plan to taper. You should certainly NOT suddenly stop taking prescribed medications (including antidepressants) without consulting your doctor.
It is also not safe to work with this plant medicine if you have any of the following health conditions.
-You are pregnant
-You have a heart condition or chronic high blood pressure
-You have a history of severe psychological problems, including bipolar mood disorder, mania, psychosis, schizophrenia, or depersonalization
Also, if you have a close / strong family history of severe mental illness, such as bipolar mood disorder, schizophrenia, or depersonalization, it is possible (although highly unlikely) that this plant medicine can unmask such symptoms in predisposed individuals. People with this family history or personal history are advised not to partake in plant medicine ceremonies. Please refer to the criteria below to make sure you:
1) have no direct history of major issues of bipolar, psychosis, or depersonalization
2) that you have not previously taken any medication for these conditions
3) are not currently taking any psychiatric medications
Provided none of these three points are applicable, the facilitator may be able to accommodate you in the plant medicine ceremonies. However, please inform us if you have any history of severe mental illness in your family, and of any medications you are currently taking, as it is crucial for your safety and your appropriateness will be assessed on an individual basis.
AGREEMENTS:
I understand that this retreat includes the optional use of traditional healing plants (also known as ‘plant medicine’). I hereby agree that I always have a choice whether or not to participate in any activity using such plants, and I agree to take full responsibility for the choices I make involving this work during and after the event.
I further agree to fully disclose my health history, including my mental health, medications, and substance use, prior to participating in any plant medicine ceremony.
I understand that approval for my participation in this work at the time of the event is entirely at the discretion of the facilitator and is not automatic.
The facilitator reserves the right to deny my participation if she deems that it would be unsafe for me or others, or for any other important reason.
To maintain the safety and trust of all participants, I hereby agree to hold this work confidential. I will reveal to no one the identity of persons participating in the plant medicine ceremonies or anything they reveal about themselves or others.
This includes maintaining confidentiality for any facilitators, helpers, or healers participating in the ceremony. I agree to participate with the intention of promoting the health and well-being of all participants.
Understanding all of the above, I will be participating in the sacred plant medicine ceremonies.
I have read and agree to the Retreat Agreement.
*
By clicking below you agree to our Retreat Agreement
I agree to purchase a timely and comprehensive travel insurance policy to cover any and all unanticipated costs due to cancellation, COVID-19, medical, loss, or any other reason. I agree that Wise Warrior Retreats is not responsible for any refunds or unanticipated costs for any reason.
*
The information I have entered above is the identifying and contact information for me, the Guest ("Guest"). It includes my legal name, address, phone number, and date of birth. I attest that all of the above information about me is true. Electronic Signature:
*
First Name
Last Name
Date of Application
*
MM
DD
YYYY
