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January 2024: Knowing Love Application & Screening 
One Spirit Infinite Journeys
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Full Name *
Email *
Phone number (Telegram or WhatsApp) *
Address *
Date of Birth *
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Gender *
Do you have any dietary restrictions or allergies? *
Emergency Contact: Name, Number & Relationship *
What are your intentions in working with the plant medicine? *
What is your past experience working with ayahuasca, psilocybin, kambo or other plant medicines? *
Do you have any concerns about working with the medicine? *
This ceremony is not appropriate for persons with certain medical conditions or for persons using certain medications. We realize that these questions may be sensitive. It is important for us to know the extent and severity of these experiences so we can support you in the best way possible during your work with the medicine. PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND HONESTLY AS POSSIBLE. YOUR RESPONSES WILL REMAIN STRICTLY CONFIDENTIAL. *
Required
Do you have a past history of, or currently suffer from any serious health conditions, diabetes, or heart conditions ? (Please elaborate) *
Are you currently pregnant or breastfeeding? If breastfeeding, how often? *
Have you ever been hospitalized for medical reasons? (Please elaborate) *
Have you ever been hospitalized for psychiatric reasons? (Please elaborate) *
Please list any medications (prescription or over the counter you are currently taking and/or have taken over the past 3 months. (Including dosage and frequency taken and for which reason they were they prescribed. Ie: sleep, anxiety, psychosis, thyroid, seizures, etc.). *
In the last 3 months have you taken:                                   --any SSRI medication like Prozac, Zoloft, Paxil, Lexapro or Celexa?                                                                                 ---any SNRIs like Effexor or Cymbalta or medications that raise dopamine like Wellbutrin or amphetamines.          If so when? For how long has the long medication been taken? What is the dosage and frequency? If you have stopped taking the medication, how long ago did you stop? (This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation.) *
In the last 3 months have you taken any MAOI medication such as Nardil, Parnate, Marplan, Zelapar, etc. If so when? For how long has the long medication been taken? What is the dosage and frequency? If you have stopped taking the medication, how long ago did you stop? (This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation.) *
In the last 3 months have you taken any TCA's or TeCA's such as Amoxapine, Loxapine, Maprotiline, Mazindol, Mianserin, Aptazapine etc. If so when? For how long has the long medication been taken? What is the dosage and frequency? If you have stopped taking the medication, how long ago did you stop? (This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation.) *
In the last 3 months have you taken any medications or products that contain Lithium etc. If so when? For how long has the long medication been taken? What is the dosage and frequency? If you have stopped taking the medication, how long ago did you stop? (This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation.) *
List any recreational substances or plant medicines that you have taken over the past 3 months. Please include when and how much. (Including alcohol, marijuana, MDMA, cocaine, heroine, ketamine, pharmaceutical medications, kava, 5MeO-DMT, bufo, kambo, kratom, LSD, psilocybin, St John's wart, ephedra, other alternative medicines) *
Do you have any history of depression, anxiety, psychosis, bipolar illness, manic episodes, or ADHD? *
I hereby confirm that I have answered all the questions completely and honestly and have not withheld any information. The information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the ceremony and in meeting my needs throughout. My general health, as far as I am aware, is good. *
Required
How did you hear about us? *
Is there anything else we should know about you before the retreat? *
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