Apply for a Retreat

Step 1: Personal Information

Full Name * As it appears on the passport

Address *

Country of Residence *

Country of Citizenship *

Phone Number *

Email *

Gender * MaleFemale

Date of birth *

Any social media or public profile link * For us to verify your identity

Occupation *

Emergency contact name and phone number *

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Step 2: Retreat Information

Why do you want to come to this retreat? *

275 characters remaining.

Do you have any previous experience with shamanic plants, with shamans, or in ayahuasca retreats? When and Where?

275 characters remaining.

Food allergies and restrictions

100 characters remaining.

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Step 3: Health Information

How do you handle crises? Explain: *

275 characters remaining.

Describe personal and/or family history of depression, psychological disorders or imbalances, suicidal thoughts. *

500 characters remaining.

Are you currently taking any kind of medication and/or supplements? *

300 characters remaining.

When was the last time you took a medicine or supplement and for what? *

300 characters remaining.

Do you or a family member have a history with substances or addictions? * Explain:

500 characters remaining.

Have you ever been hospitalized? Why and when? *

500 characters remaining.

Health insurance for travel - company and policy number:

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Step 4: Reservation Information

Date *
Select one

October 3 — October 11 2023 - 9 days, 4 ceremonies
November 15 — November 25 2023 - 11 days, 5 ceremonies
December 13 — December 21 2023 - 9 days, 4 ceremonies
January 9 — January 19 2024 - 11 days, 5 ceremonies
February 20 — February 28 2024 - 9 days, 4 ceremonies
March 26 — April 5 2024 - 11 days, 5 ceremonies
April 26 — May 4 2024 - 9 days, 4 ceremonies
June 4 — June 12 2024 - 9 days, 4 ceremonies
July 9 — July 19 2024 - 11 days, 5 ceremonies
August 14 — August 22 2024 - 9 days, 4 ceremonies
September 17 — September 25 2024 - 9 days, 4 ceremonies
November 5 — November 15 2024 - 11 days, 5 ceremonies
December 13 — December 21 2024 - 9 days, 4 ceremonies

What type of accommodation do you prefer? * Prices listed are per person
Two Person Shared BungalowThree Person Shared BungalowFive Person Mixed DormitoryPrivate Bungalow

How did you learn about us? *
GoogleFacebookYouTubeInstagramTwitterLinkedInAya AdvisorsInternetForum/Blog postFriend/Family (mention full name in comments)Other

Any other comments?

100 characters remaining.

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