ceremony Participation Medical Questionnaire – Companionship of the Sacred Vine

This form MUST be filled out and submitted before you can book a session

Your details are kept strictly conﬁdential and are only used by the Companionship for contacting you about your ceremony or after-care support.

The ceremony facilitator must receive this form as part of your registration for your ceremony. We cannot conﬁrm your place at the ceremony until you have completed this form.

Information about the Ceremony

Companionship Ayahuasca ceremonies are intended to be a personal 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.

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 organizers of your ceremony.

Application Form

Please answer all questions as fully as possible.

Confidential Health Questionnaire For Ayahuasca Sessions

It is vitally important that you answer all questions in this form as honestly and as fully as possible. No one outside of CSV facilitors are allowed to see this information and your answers to these questions are used to assess your suitability to participate in a CSV ayahuasca session only. TAKE YOUR TIME - you can save this form and come back to it later (save button at bottom of the form). This form MUST be filled out prior to your attendance at a CSV ayahuasca ceremony. HOWEVER, facilitators have the final say as to who is allowed to attend their ceremonies. If you have any questions about this, please contact your facilitator or the CSV.

Name*

First

Last

City*

Province/State/Region*

Country*

Date of Birth*

day

month

year

Today's Date mm/dd/yy*

Email*

Phone*

Do you currently suffer from any cardiovascular disease or have you had a heart attack?

Yes

If YES, Please Indicate or provide history*

Do you have high blood pressure?*

Yes

If yes, please indicate severity and history of your high blood pressure and any medications you are taking

Please indicate if you have any psychiatric condition(s)

Yes

If YES please provide details of any psychiatric conditions

Are you being actively treated for any psychiatric condition at this time?

Yes

If yes please describe your treatment program and list any medications you are currently taking.

Do you have or have you been treated for psychiatric disorders that included a psychotic break such as schizophrenia, psychosis, personality disorders, bipolar disorder or other conditions of this nature? If so, taking Ayahuasca involves a high degree of risk, especially if your disorder is active. If you suffer from any of these disorders and are still convinced that you want to have an Ayahuasca experience, it is very important that you openly discuss this with the facilitator of the session. The facilitator may or may not allow you into their session at their own discretion. Do you have a history of this type of psychiatric disorder(s)? *

Yes

If you answered YES to the above question, please indicate your history of disorders that involved a psychotic break and any medication you are taking for treatment.

Have you ever been hospitalized for a psychiatric condition or event?

Yes

If Yes, what psychiatric condition/event were you hospitalized for and when? If multiple times, please indicate why and approximate month/year and any medication you are taking for treatment.

Is there anyone in your family history with a history of severe psychiatric disorders or conditions?

Yes

If Yes, please provide the details and history

Are you currently receiving therapy or attending any kind of support group?

Yes

If Yes, what therapy or support group are you attending?*

Have you had any surgeries or operations within the last five years?

Yes

Please indicate your surgeries or operations and when

Have you had or do you have any significant physical injuries or impairments?

Yes

Please indicate your injuries or impairments*

Do you have any infectious or contagious diseases?*

Yes

Please indicate your history infectious or contagious diseases and any treatment program. Include any medications you may be taking for treatment.

Are you pregnant? Please note - if you are pregnant you will be eligible for a ceremony after childbirth.

Yes

Expected Date of Childbirth mm/dd/yy*

Have you been hospitalized in the last 10 years for any physical conditions?

Yes

If Yes, what were you hospitalized for and when? If multiple times, please indicate why and approximate month/year.

Are you currently taking any medication(s) or herbal supplements?

Yes

If Yes, please indicate the medication(s) or herbal supplements you've been taking and for how long?

Is there anything else about your physical or emotional state that the facilitator should be aware of?

Yes

If Yes, please indicate what physical or emotional conditions your facilitator should be aware of prior to you going to the Session.

Have you ever taken ayahuasca before?*

Yes

If Yes, please indicate the number of times you've taken ayahuasca and the circumstances.

Have you had difficulty integrating your ayahuasca experience(s) or did you experience any significant adverse effects? (If you haven't taken ayahuasca, check "No"

Yes

If Yes, please outline any adverse effects or difficulties with integration.

Have you taken other psychoactive substances and had difficulty integrating or processing the experience?

Yes

Please indicate the substances you used and what adverse experiences you had?

Do you take any other legal or illegal recreational drugs on a regular basis?

Yes

Please indicate the substances you use on a regular basis.

Please provide a name and contact number for a next of kin or emergency contact should problems arise in the Session. 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 ayahuasca session of my own free will and on an informed basis.

Yes I understand the risks