If you’re wondering what questions you’ll be asked prior to your first ceremony in the Companionship – please see below.
PLEASE NOTE – an online fillable form will be available to Companionship members when we are able to conduct legal ceremonies, pending our Health Canada application for exemption to serve ayahuasca.
The form only needs to be filled out once or if any significant new problems occur.
Your facilitator must receive this form as part of your registration for your ceremony. We cannot confirm your place at the ceremony until this is completed.
Your details are kept strictly confidential and are only used by the Companionship for contacting you about your ceremony or after-care support. You may be asked for additional details about your physical/mental health based on your answers to the following questions.
Information about the Ceremony
Companionship ayahuasca ceremonies are intended to be a spiritual growth experience. Working with ayahuasca can involve intense experiences accompanied by strong emotional and physical releases. It is not recommended for people with serious cardiovascular problems, serious hypertension, severe psychiatric conditions (check with your facilitator), recent fractures or surgery, acute infectious diseases, or spiritual emergencies.
A decision-making guideline on whether to attend a ceremony is posted on our website here.
If you have any doubt as to whether you should participate in the ceremony you may want to consult your doctor or therapist as well as the organizer(s) of your ceremony.
Application Form
Please answer all questions as fully as possible.
Name*
First
Last
City*
Province/State/Region*
Country*
Date of Birth*
day/month/ year
Today’s Date*
Phone
Do you currently suffer from any cardiovascular disease or have had a heart attack? *
Yes
No
Do you have high blood pressure?*
Yes
No
Please indicate if you have any psychiatric condition(s)*
Yes
No
Have you had any recent surgeries or operations?*
Yes
No
Have you had or do you have any significant physical injuries or impairments? *
Yes
No
Do you have any infectious or contagious diseases?*
Yes
No
Do you have any of the following conditions?*
Glaucoma
Displaced Retina
Epilepsy
Osteoporosis
Asthma (if yes please bring inhaler)
None of the above
Are you pregnant?*
Yes
No
Have you been hospitalized in the last 10 years for any physical conditions?*
Yes
No
Have you ever been hospitalized for a psychiatric condition or event?*
Yes
No
Is there anyone in your family history with a history of severe psychiatric disorders or conditions?*
Yes
No
Are you currently receiving therapy or attending any kind of support group?*
Yes
No
Are you taking any medication(s)?*
Yes
No
Is there anything else about your physical or emotional state that the facilitator should be aware of?*
Yes
No
Have you ever taken ayahuasca before?*
Yes
No
Did you have difficulty integrating your ayahuasca experience(s) or did you experience any significant adverse effects?*
Yes
No
Have you taken other psychoactive substances and had difficulty integrating or processing the experience?*
Yes
No
Do you take any other legal or legal recreational drugs on a regular basis?*
Yes
No
Please provide a name and contact number for a next of kin or emergency contact should problems arise in the ceremony. If none, state “None”*
Please read and acknowledge the following declaration – I declare that I have read and understood the information in this form. I further declare that I have answered all the above questions fully and honestly and have not withheld any information that I believe could be important. *
Yes I have answered honestly and completely
I am aware of the risks associated with the use of ayahuasca and I consent to participating in any ceremony of my own free will and on an informed basis.*
Yes I understand the risks