First Name
Last Name
Phone
Country
Email
Confirm Email
Gender
Male
Female
Rather Not Say
Date of Birth
Language Spoken
If you have selected a Shared Room, are you attending with a friend or partner, who you would like to share with? Please enter name
Emergency Contact Full Name
Relationship to Participant
Emergency Contact Phone Number (Please include country code)
Emergency Contact Email Address
Health Insurance Provider and Policy Number (if applicable)
Please describe your motivation for wanting to participate in a plant medicine ceremony. What specific experiences or challenges lead you to this decision?
Detail your previous experiences with psychedelics, including plant medicines, and describe how they impacted your personal development and emotional well-being?
Describe a significant challenge or transformative event in your life and how you handled the changes it brought. How do you think this experience has prepared you for plant medicine?
If you have selected yes to any of the above, please detail any ongoing mental health treatment or therapy.
Detail any significant health issues you have had in the past five years, including how they were managed and/or resolved. How do you currently maintain your health?
How do you currently manage stress and emotional challenges in your everyday life? Please provide examples of strategies or practices you use.
What does spiritual connection mean to you, and how do you currently explore or express your spirituality?
What are your intentions for this Plant Medicine ceremony? What outcomes would make it successful for you?
Please list all the medications and all supplements you are currently taking in the box below (e.g. Prozac, Lexapro, Valium, etc.)
Do you have any chronic diseases/conditions? If so, please list the name of the medications currently used.
Do you have any known allergies? If so, please elaborate.
Do you have any conditions with the kidneys? If so, please describe.
Do you have high blood pressure? If so, please state the latest blood pressure values.
Do you have Thalassemia or Thalassemia trait?
Illegal and recreational drugs are dangerous combined with some MOAIs. Please list all the substances used in the last 30 days in the box below (MDMA, Cocaine, Methamphetamine, etc.)
Do you have any fears regarding attending the ceremony?
Describe your support system. Who in your life understands or supports your decision to explore plant medicine? How do you plan to integrate your experience post ceremony with their help?
Please provide details of your forward travel plans at the completion of the retreat (e.g., flight details, accommodation arrangements, etc.). Please note: Going on this journey is a profound experience, and we recommend allowing yourself adequate time to reintegrate. It's best to set aside a few days afterward to decompress before resuming your daily routine or catching a flight. This time is essential for your overall well-being, ensuring that you fully benefit from the transformative experience.
Waiver Liability Release & Informed Consent
Introduction: Welcome to Plant Medicine Thailand, where ancient Amazonian traditions meet Eastern spiritual practices. Our retreats are guided by experienced Shamans rooted in the Shipibo tradition from Peru, blended with Buddhist and Hindu teachings. We honour and integrate diverse spiritual paths to create a unique environment for growth and healing.
Waiver and Release: By participating in our retreats, you release Plant Medicine Thailand, its agents, and associated individuals from liability for any physical, emotional, or psychological injuries that may occur. You acknowledge the inherent risks involved in participating in plant medicine ceremonies and therapeutic techniques.
Assumption of Risk: You understand that plant medicine ceremonies may involve physical and emotional challenges. By choosing to participate, you assume all risks and accept responsibility for any effects, including, but not limited to, nausea, vomiting, intense emotional fluctuations, and visionary states, which are considered part of the healing process.
Participant Responsibilities: To ensure your safety and the integrity of the retreat, you confirm you have complied with all pre-retreat instructions provided:
Preparation: Followed all preparation guidelines, including dietary restrictions and abstaining from prohibited substances.Medical Disclosure: Provided complete and accurate information regarding your medical and psychological history by thoroughly filling out our health questionnaire. Failure to disclose relevant information could lead to serious health risks.
Ceremony Protocols: To ensure your safety and the integrity of the retreat, you agree to:
Guidance and Facilitation: Conduct: Voluntary Participation:
Insurance: You understand that Plant Medicine Thailand does not assume any responsibility for or obligation to provide you with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance of any nature in the event of injury, illness, death, or damage to property. You expressly waive any such claim for compensation or liability on the part of Plant Medicine Thailand beyond what may be freely offered in the event of such injury or medical expense incurred by you.
Additional Support and Associated Costs: In the event that you require additional support following an adverse reaction to plant medicine during or after the retreat, Plant Medicine Thailand will strive to provide appropriate assistance. Please be aware that any extra costs incurred as a result of this support will be your responsibility. These costs may include: accommodation, meals, travel and other incidentals:
Legal Considerations:
Compliance with Local Laws: You agree not to engage in any activities that could bring legal jeopardy to yourself or the organisation.Liability Waiver: You acknowledge that participation in these ceremonies carries inherent risks and agree to release Plant Medicine Thailand, its staff, and affiliates from any claims related to injuries or damages arising from your participation.
Cancellation and Refunds: We understand that unforeseen circumstances can arise. While we do not offer refunds, any deposits paid can be transferred to a future retreat, allowing you to preserve your investment in your healing journey. This policy ensures flexibility and supports your commitment to personal growth, even if your plans change.
Privacy Policy: Your privacy is paramount. All personal and health information will be handled with the highest degree of confidentiality and used solely to ensure your safety and compatibility with our retreat offerings. Your information will not be shared with third parties without your explicit consent.
Final Acknowledgment: By engaging with Plant Medicine Thailand and participating in our retreats and ceremonies, you acknowledge that you have read, understood, and agree to all the terms and conditions outlined in this Waiver, Liability Release, and Informed Consent document. This agreement is designed to ensure a safe, respectful, and transformational experience for all participants.
Send
