Ayahuasca Questionnaire

Name:(required)

Phone:(required)

E-mail:(required)

Address:(required)

Date of birth:(required)

Preferred Event Date?(required)

Do you use any medication? If so, which ones?(required)

Quantity / day(required)

Reason / pathology:(required)

Are you currently under the care of a doctor or therapist, and if so, for what?(required)

Do you have high blood pressure or heart disease? Or in the past?(required)

Do you have experience with Ayahuasca or other Entheogens? If so, which ones?(required)

Where did you first hear about Ayahuasca?(required)

Would you tell something about your motivation to participate in an Ayahuasca session?(required)

What would you like to heal, or which insights would you like to get?(required)

Are there any further details of physical or emotional nature that could be important for us to know?(required)

World on Ayahuasca