Medicine Journey

Application

Thank you for your interest. This form helps us get to know you and care for your safety and the safety of the group. It takes about 10 minutes.

Please answer honestly and completely. Your answers are confidential: they are read only by the Ashiyana team and used only to assess your participation. Answering "yes" to a health question does not automatically exclude you, it helps us talk with you about it.

About you

Full name

WhatsApp (with country code)

Age

Country and city where you live

Languages you speak

Emergency contact (name, relationship and phone)

Your intention

Why do you want to take part in the Medicine Journey?

What would you like to work on or transform in this journey?

Do you have a body, meditation or spiritual practice? Tell us about it.

Previous experience with ayahuasca or other plant medicines

None1 to 3 times4 times or more

If you have experience, how was it? Was any experience difficult or hard to integrate?

Physical health

Do you have, or have you had, any of the following?

Heart disease, arrhythmia, high blood pressure or a history of stroke YesNo

Epilepsy or seizures YesNo

Diabetes, liver or kidney disease YesNo

Pregnancy, trying to conceive or breastfeeding YesNo

Surgery or serious injury in the last 6 months YesNo

Any other physical condition, allergy or limitation we should know about YesNo

Medications and substances

Some medications interact dangerously with ayahuasca. Please list everything, including natural supplements.

Are you currently taking any prescription medication? YesNo

Have you taken antidepressants or other psychiatric medication in the last 3 months (for example SSRIs, SNRIs, MAOIs, tricyclics, lithium, antipsychotics, benzodiazepines)? YesNo

Do you take ADHD stimulants, tramadol, St John's wort, 5-HTP or other supplements? YesNo

Have you used recreational drugs or drunk alcohol regularly in the last 3 months? YesNo

Mental and emotional health

These questions are asked by every responsible ceremony. Please take your time.

Have you ever been diagnosed with or treated for psychosis, schizophrenia, bipolar disorder or a personality disorder? YesNo

Has a parent, sibling or child of yours been diagnosed with psychosis, schizophrenia or bipolar disorder? YesNo

Are you currently going through depression, anxiety, panic attacks or post-traumatic stress? YesNo

Have you had suicidal thoughts or harmed yourself in the last 12 months? YesNo

Have you ever been hospitalised for mental health reasons? YesNo

Are you currently in therapy or psychological or psychiatric follow-up? YesNo

Practical details

Dietary restrictions or food allergies

Room preference

Shared roomPrivate roomNo preference

How did you hear about the Medicine Journey?

Anything else you would like us to know?

Agreements I am 18 years old or older. My answers are true and complete, and I will let Ashiyana know if anything changes before the retreat. I understand that the Medicine Journey is a ceremonial and therapeutic experience and does not replace medical or psychological treatment. I will not stop or change any prescribed medication without the guidance of my doctor. I will follow the preparation guidelines sent by Ashiyana, including the diet and abstaining from alcohol and drugs before and after the ceremony. I understand that participation in the ceremony is voluntary and that I may choose not to take part at any moment. I consent to Ashiyana Brasil storing and using my answers, including health information, only to assess and care for my participation. I can ask for them to be deleted at any time.

Thank you, we received your application

Our team will read your answers with care. We will contact you personally by email or WhatsApp with our answer, the dates and values of the next edition and the preparation guide.

If you have any question in the meantime, write to us on WhatsApp.

Back to the Medicine Journey WhatsApp