Metsá-Kabi Retreat — Participant Intake

Participant Intake

Before we begin

This form helps us understand you — your history, health, intentions, and what you are carrying into the ceremony space. Please answer as honestly and fully as you can. Everything shared here is held in strict confidence.

Completion of this form does not guarantee a place in the retreat. We review each intake personally and will reach out to confirm your reservation.

Retreat Date

Which retreat are you applying for?

September 25 – October 6, 2026 November 8 – 20, 2026 November 28 – December 10, 2026

Personal Information

Full Name

Date of Intake

City & Country

Phone / WhatsApp

Date of Birth

Occupation

Gender

Relationship Status

Emergency Contact

Intentions & Background

1. Tell us about yourself. Who are you, where are you in your life, and what draws you to this retreat?

2. What is your intention for coming to work with the medicine? What are you hoping to heal, understand, or receive?

3. Have you worked with ayahuasca or other plant medicines before? If so, describe your experience.

4. Is there anything in your life right now — a relationship, a transition, a loss, a fear — that feels most alive or pressing?

Mental Health

5. Do you have a personal or family history of mental illness (depression, anxiety, psychosis, schizophrenia, bipolar disorder, etc.)? Please describe.

6. Have you ever experienced a psychotic episode, dissociative episode, or break from reality?

No Yes

7. Have you ever been diagnosed with or treated for PTSD or complex trauma?

No Yes

8. Please share any trauma history you feel comfortable disclosing — physical, emotional, sexual, or otherwise. This is held with care.

9. Are you currently seeing a therapist, psychiatrist, or mental health professional?

No Yes — please describe below

Substance Use

10. Please indicate your current use of the following substances. This information is held in strict confidence.

Alcohol

Cannabis

Tobacco / Mapacho

Stimulants

Entheogens

Other

11. Have you ever struggled with addiction or dependency? Please be honest — this information is handled with care.

12. Have you used any substances (recreational or otherwise) in the past 30 days? If so, please list them.

Physical Health

13. Do you have any current or chronic health conditions, illnesses, or diagnoses we should know about?

14. Do you have any heart conditions, high blood pressure, or cardiovascular concerns?

No Yes — please describe below

15. Are you currently taking any prescription medications? Please list all medications, dosage, and reason.

MedicationDoseReasonSide Effects

16. Do you have any food allergies or dietary restrictions?

17. Describe your general physical health, exercise habits, and any injuries or limitations.

18. Is there anything else about your physical health we should know?

Spiritual & Personal Life

19. Do you have a spiritual or contemplative practice? Describe your relationship to the sacred, prayer, or inner work.

20. Describe your work life. Do you find meaning in your work? What is your relationship to it?

21. Describe your primary relationships — family, partner, close friends. What is alive there?

22. What major life changes or transitions have you moved through in the past year?

23. What are you currently reading? Name three books that have shaped you most.

24. Three films that move you.

25. What's on your playlist?

26. Is there anything else you'd like us to know before we meet?

By submitting this form I confirm that all information provided is truthful and complete to the best of my knowledge. I understand that this retreat involves working with powerful plant medicines and I accept responsibility for my own wellbeing and participation.

Signature (full name)

Date

Thank You

Your intake form has been received. We read each one with care and will be in touch personally within a few days to discuss your place in the retreat.

Ayni.medicinas@gmail.com · +1 347 324 6759