Intake, Waiver and Release Form for Ceremony - May 22, 2024
This medical screen intake and waiver must be completed prior to the start of each ceremony. Even if you have participated in a ceremony with us before, a new intake form must be completed prior to each ceremony. ALL RESPONSES ARE KEPT CONFIDENTIAL AND PRIVATE. THIS INFORMATION WILL NOT BE SHARED WITH A THIRD PARTY.
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Email *
First Name *
Last Name
*
Phone Number to follow up for a short call.   Include Country Code (US and Canada +1)
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Is your phone number linked to a WhatsApp Account?
*
Required
Do you have experience with plant medicine or psychedelics? *
Required
If yes to the previous, what plants or substances have you used socially or in ceremony?    List all substances (Example : alcohol, cannabis, cocaine, mushrooms, MDMA, ayahuasca, kanna, etc...)
What prescription medications are you taking? (list all here as well as amount and how often you take them) *
What over the counter medications are you taking? (list all here as well as amount and how often you take them) *
What herbs and supplements are you taking? (list all here as well as amount and how often you take them) *
Do you have a history of schizophrenia, psychosis, bi-polar condition, seizures, or other mental health diagnosis? *
If yes to prior question provide details.
Do you have a heart condition or a history of heart problems (choose all below)? *
If yes to prior question provide details.
Are you pregnant? *
Do you have any food restrictions?
Do you have any food allergies? *
If yes to above, please list.
Are you a Costa Rica resident (live in Costa Rica 10 out of 12 months a year), citizen, or visitor *
How many days will you be staying in Costa Rica after the ceremony?  (We strongly suggest allowing at least 1 full day of integration post ceremony before taking a long trip or flight)
*
In order to secure your spot for this ceremony a $100 non-refundable deposit is required.   Please indicate that you have read the statement of deposit.  You can pay with Zelle ( paul.jarreau@gmail.com ), Venmo ( @Paul-Jarreau ), or PayPal (friends and family payment paul.jarreau@gmail.com ), Revolut (@ronaldnikel)
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