New Ceremony Application

Today's Date

Date of Ceremony you wish to partake - Required*

2021 Ceremony dates are: June 11-14 (Women Only), Jul 9-12 (Mixed gender), Aug 13 to Aug 24 (12 day Retreat) Check Ceremony Calendar for updates

Name - Required*

First Name Last Name

Address

Street Address City State/Prov/ Postal Code

Best Phone # to reach you - Required*

Format (xxx) xxx-xxxx

Best email address to reach you - Required*

Enter Email Confirm Email

Birth date - Required*

Occupation

Emergency Contact - Required*

You must provide the name of you emergency contact. It cannot be the same name or telephone number as yourself.

First Name Last Name

Emergency Contact Email - Required*

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Emergency Contact Phone # - Required*

Format: (xxx) xxx-xxxx

Doctor's Name

First Name Last Name

Doctor's Contact Phone #

Please enter 555-555-5555 if you do not have a physician

Do you have experience with psychedelic/entheogenic plant spirit medicine? (like Ayahuasca, San Pedro, Mushroom) - Required*

How many years of experience do you have with spiritual and/or personal development? - Required*

What is your experience with meditation, dancing and body work? - Required*

What would you like to look into/release or bring into balance with Grandmother medicine? - Required*

What is your intention for your healing process with Grandmother Medicine? - Required*

“It is important to formulate an intention when journeying with Plant Spirit Medicine as a point of focus for your preparation for the journey. But it's also important to distinguish between intention and expectations, because the way to your intention is, most likely, not through achieving your expectations, because your expectations are largely part of your consciousness and so much of what Ayahuasca is, relates to your subconscious and that which is even greater or outside of us, which your consciousness knows nothing about. In fact, you can achieve your intention, even though it does not feel as if you have, because what you experienced was part of some necessary preparatory healing or because you received a precise but indirect answer”. A good intention is like having a map for reaching the wisdom that will help you in your healing journey. Please be specific with a realistic Intention. You do not get into your car and drive without a destination in mind. Intention is the direction of your journey.

Please describe your medical history, past and present conditions. - Required*

Explain any body aches and pains, PTSD, anxiety, childhood trauma, any suspected abuse or anything that is causing you to feel less then.

Are you taking any of the following groups of medications? - Required*

Many medications prescribed by your doctor maybe incompatible with these ceremonies.

Do you have a heart condition, or have you ever had an ECG test to screen for this? - Required*

Do you have allergies or dietary requirements? - Required*

What spiritual practices if any, do you engage in? - Required*

What daily practice do you do that anchors you soul into form?

I agree to follow and commit to the Pre & Post diet guidelines found on this website and I certify that I have answered truthfully all questions. - Required*

YES
NO

If you were referred by someone, please let us know

Any other information you would like to convey that we may hot have asked?

Application Supplemental Notes - Required*

If you did not receive a confirmation email that your form has been received, it is more and likely that you missed one item in the form. Once your application has been Received, we will call you to complete your telephone interview. This process is not immediate and can take up to a week or more. Please DO NOT make travel arrangements until you have been approved. Please note, your space is not confirmed until you have made your deposit. Your payment MUST be received within 7 days from your application approval, otherwise you will need to re-apply when you are ready to sit in sacred space. Should you face any medical challenges in attending the ceremony you have purchased, we will gladly offer you to sit in another one. There is no refunds.

I understand that until my deposit is made my reservation is not confirmed.

Consent - Required*

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Phone

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New Ceremony Application

Plant Spirit Ceremony Application