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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
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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 South American traditions meet Eastern spiritual practices. Our retreats are guided by experienced Shamans rooted in the Shipibo tradition from Peru and the Huni Kuin, Yawanawá and other Brazilian traditions, blended with Buddhist and Hindu teachings. We honour and integrate diverse spiritual paths to create a unique environment for growth and healing. These terms apply to all plant medicines served by Plant Medicine Thailand, and to all of our group retreats, private ceremonies and private experiences.
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: Adhere to all instructions provided by our experienced facilitators and Shamans during ceremonies to maintain safety and the integrity of the experience.Conduct: You will conduct yourself respectfully towards all participants and facilitators.Voluntary Participation: Your participation in all ceremonies is entirely voluntary. You have the right to withdraw at any point if you feel unable to continue. However, we encourage completing the full journey to fully experience the depth of healing and transformation our ceremonies offer.
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.
Nature of the Medicine and Outcomes: Sacred plant medicines work differently with each person, and every ceremony is unique. Some people experience strong physical, emotional or visionary effects. For others, the experience is subtle, or its effects unfold gradually in the days and weeks that follow. We cannot predict or guarantee the intensity, nature or outcome of any ceremony. The experiences described on our website and in our materials reflect what others have shared, and are not a promise of what you will experience.
Cancellation, Refunds and Transfers: All payments made to Plant Medicine Thailand, including deposits and full fees, are non-refundable. This policy applies to all of our offerings, including group retreats, private ceremonies and private experiences. Payment is only requested once your application has been reviewed and approved.
Before Your Retreat: We understand that unforeseen circumstances can arise. If you need to cancel, any payments made can be transferred to a future retreat or ceremony held within 12 months of your original date. Please let us know as early as possible, ideally at least 30 days before your start date so there is time to begin your dietary preparation, and no later than 14 days before your start date.Once Your Retreat Has Begun: No refunds or transfers are offered once a retreat or ceremony has begun. This includes if you choose to leave early or decide not to take part in a ceremony.After Your Retreat: No refunds are offered after a retreat or ceremony has taken place. This includes where your experience was different from what you expected or hoped for, as outlined in Nature of the Medicine and Outcomes above.Removal From a Retreat: If you are asked to leave a retreat for safety reasons, a breach of these terms, or because relevant medical information was not disclosed, no refund or transfer will be offered.Goodwill Gestures: From time to time, Plant Medicine Thailand may choose to offer a credit or a place at a future ceremony. Any such offer is made entirely at our discretion, as a gesture of goodwill, and does not change this policy.
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.
How did you find out about Plant Medicine Thailand
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