Wisdom Weekend – Forest Path Ceremonies – Jul 4 & 5 – Santa Barbara, CA

Retreat Guru is the online booking agent for Forest Path.

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First Name *
Last Name *
Email *
Phone
Gender
Birth Date
Emergency Contact Info *
Emergency Contact Number
Is this your first time sitting with Ayahuasca?	Yes No
Who is recommending you?
You agree to the following.	The information provided above is a complete and accurate statement of the physical and psychological factors which may affect my participation in the Works of Forest Path. I realise that failure to disclose such information could result in serious harm to me and/or fellow participants and I agree to indemnify and hold harmless Forest Path if all relevant information is not disclosed. I also agree to notify Forest Path should there be any changes in my health status. I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good.
Reason for counseling (if applicable):	Academic Suicide Depression Substance Abuse Career Divorce Family Issues Other
Is there anything else about your health status of which we should be aware of?
Please elaborate on anything that was checked YES in the previous question.
To assist us, please check the boxes that apply to your current or past condition. Your responses will remain strictly confidential.	Cardiovascular disease, including heart attacks High blood pressure Recent surgery Prone to seizures now or in the past Any pre-existing heart conditions Recent or current infectious or communicable diseases Pregnant Been hospitalized within the last 2 years Have a psychiatric diagnosis Been hospitalized for psychiatric reasons Pre-existing mental health issues Currently in therapy or involved in a type of support group Have been in counseling with a psychiatrist, psychologist, or other counselor within the past two years Use medication None Stroke Diabetes Stomach/ GI Issues TBI/ Traumatic Brain Injury COPD/ Chronic Obstructive Pulmonary Disease Please tick any relevant conditions you have experienced. Forest Path does not provide medical or mental health clearance to participate in its events. For such a clearance, please consult with a qualified medical or mental health professional. Forest Path’s ministerial assessment means it is performed without diagnosis or the use of medical or therapeutic services or determinations, even where developed based on available medical information about contraindications and non-medical criteria that create excessive risks.
Are you taking any form of medication? If yes, please state its name, how long you have been taking it and what it is for.
You agree to the terms and conditions.	The undersigned hereby seeks to participate in the Céu do Som Work and understands that the Centre desires to ensure the safety of all participants. In order to assist Céu do Som in this regard, I agree to complete the Confidential Medical history form provided. I am assured that the information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the work and in meeting my needs before, during and after the ceremony. I have been informed of the nature of those works, the needed preparations and the rules of the ceremonies. I commit myself to stay in the Centre until the end of the ceremony and to respect the directives given by the guardians named by the Facilitator of the session.
Please state your personal reason for attending.
Do you have any experience with mental/psycho-spiritual disciplines? i.e. Yoga, Meditation.

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