Transform Womxn's Retreat Intake Form
Email address *
Full name *
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Telephone # *
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Birthdate *
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Emergency Contact Name, Phone # and Relationship *
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What has called you to this work? What are you hoping to receive from coming on retreat and drinking medicine in Peru? *
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Please describe any previous experience working with plant medicines *
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Are you vegetarian/ vegan or do you have any special dietary needs? *
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Medical History
THE TRADITIONAL SHIPIBO AMAZONIAN MEDICINE CEREMONY IS ROOTED IN THE ANCIENT PRACTICE OF FINDING THE CURE. THE INTENTION TO BRING THE BODY BACK INTO ITS WHOLE STATE. THIS IS ONE OF THE OLDEST FORMS OF SHAMANISM, THE SHIPIBO TRADITION ITSELF IS ONE OF THE OLDEST EXISTING IN THE AMAZON. PARTICIPATION IN THE CEREMONIES CAN INVOLVE DRAMATIC EXPERIENCES ACCOMPANIED BY STRONG EMOTIONAL AND PHYSICAL RELEASE. THIS CEREMONY IS NOT APPROPRIATE FOR PERSONS WITH CERTAIN MEDICAL CONDITIONS OR FOR PERSONS USING CERTAIN MEDICATIONS. PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND HONESTLY AS POSSIBLE. YOUR RESPONSES WILL REMAIN STRICTLY CONFIDENTIAL.
Do you have a past history of, or currently suffer from any serious health conditions? If yes, please explain *
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Are you currently pregnant or breastfeeding? If breastfeeding, how often? *
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Have you ever been hospitalized for medical reasons? (If yes, please explain) *
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Have you ever been hospitalized for psychiatric reasons? (If yes, please explain) *
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Are you currently taking any type of medications? If yes, please list the medications dosage and frequency taken. Please note that it is imperative that you list all medications, as the plant medicine can interact with certain medications in a way that can be dangerous. *
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Have you ever taken SSRI medication for depression? If so when? For how long? *
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List any medications that you have taken in the past 12 months.(Prescribed or over the counter) Please include dosage and frequency taken. *
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List any recreational substances that you have taken over the past 12 months. (Including alcohol and marijuana) *
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Do you have any history of depression, anxiety, psychosis, bipolar illness or ADHD? Please note that ceremonies should not be seen nor are they designed as a substitute for psychiatric or other medical care *
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Have you ever been a victim of physical or sexual abuse? We realize that this is a sensitive matter. 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. *
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I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good. *
I the undersigned hereby seek to participate in a traditional Shipibo Amazonian medicine ceremony. I agree to complete the Confidential Medical history form provided. I am assured that 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 before, during and after the ceremony. *
Please type your full name and today's date in the box below to sign and complete this form *
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A copy of your responses will be emailed to the address you provided.
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