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Rainforest Medicine Gathering Application
PARTICIPANT PRE-SCREENING & QUESTIONNAIRE

Please respond to each question to give us an understanding of who you are, why you’d like to attend and how we can be of service.
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* Required
Email *
Your email
Dahlia Miller *
Your answer
Contact # *
Your answer
How did you learn about this Rainforest Medicine offering? *
Your answer
Emergency Contact (Name & Relationship) *
Your answer
Emergency Contact # *
Your answer
Skype (if available) *
Your answer
Birthday *
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Age *
Your answer
Gender *
Passport expiration date *
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Which country are you from? *
Your answer
*
Because Costa Rican authorities require a yellow-fever vaccine certification from travelers of the following countries: Angola, Benin, Burkina Faso, Cameroon, Democratic Republic of Congo, Gabon, Gambia, Guinea, Liberia, Nigeria, Sierra Leon, Sudan, Bolivia, Venezuela, Brazil, Peru, Colombia, Ecuador and Guyana, even if you were only transiting (a stop-over) through any one of these countries. Please contact the Costa Rican consulate in your country to ask how many days prior to arriving into Costa Rica do they require that you have the yellow fever vaccination. If so, you must travel with your yellow fever vaccination card to show the Costa Rican officials at Santa Maria International in San José. If you are over 60 years of age, although you may be exempt from the vaccination, you must provide a doctor to sign off on a RX pad saying you are not advised to take the vaccination. For other exemptions, please read:  http://www.costarica-embassy.org/index.php?q=node/97
Your answer
Occupation *
Your answer
What is your reason for attending? *
Your answer
Date of the event *
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Date and Time of International Arrival *
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Time
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Date and Time of International Departure *
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Time
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What type of experience have you had with entheogenic plants? *
Your answer
Is this your first time exploring the use of sacred ancestral rainforest medicine? (Banisteriopsis caapi and admixture preparations) *
If yes, how many times? *
Your answer
How has your experience(s) been? *
Your answer
How has your experience(s) changed your outlook on life? *
Your answer
Please read this list, specifically "Food and Medication to Avoid." Have you read the list thoroughly? *
http://www.ayahuasca.com/science/foods-and-meds-to-avoid-with-maois/
Have you ever had / or are currently experiencing any of the following medical conditions (Please select all that apply): *
Required
Have you ever had / or are currently experiencing any of the following mental conditions (Please select all that apply): *
Required
Do you have any health issues that you want us to be aware of? (Please list all, including any physical, mental, past injuries or traumas and their history.) *
Your answer
Have you ever been diagnosed, treated or self-diagnosed as an alcoholic or drug-addict? *
If so, please write a brief paragraph about any substances which you may have used or are currently using, how often you would use and your perceived relationship to them. *
Your answer
Please list any pharmaceutical medications you are currently taking, or have taken within the past 6 months. *
Your answer
Are you currently taking, or have you recently stopped taking any form of antidepressants? If so, please write the name(s), dosage(s), duration and the date(s) you stopped. *
Your answer
Within the past 6 months, have you recently stopped taking any natural supplements, herbal medicines or vitamins including St. John wort, 5-HTP, SAM-e, Kava or anything else listed on link above regarding foods and medications to avoid? If so, please list the names and dates you stopped taking them *
Notes: The above meds-to-avoid can potentially make your ceremonial experience seriously contra-productive to your health. The foods-to-avoid in the above website are best to avoid at least 2 weeks prior to your rainforest medicine council date.
Your answer
Do you use Cannabis for medicinal purpose? Or for other reasons? if so, describe your usage. *
Your answer
Do you use other plants for medicine? If so, to what extent? Why are you using? and how do you feel they are helping you? *
Your answer
 For women: Will you be expecting your menstrual cycle during the retreat?
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If so, please consider participating on a different date, given that women on the moon time are not permitted to participate in the Ancestral Rainforest Medicine ceremony. If your menstrual cycle were to come unexpected, this is still the case. Please note though, we do have alternative activities for cleansing and healing that we can offer you if you choose to come to Guaria during a council.
Required
If you are a woman and your menstrual cycle comes during the council, are you in consent that you will not be able to participate in the plant medicine ceremony until the cycle has fully passed? *
Note: There are traditional regulations that prohibit the drinking of the medicine while on one’s moon cycle and there are very specific health reasons for this as well. Our intentions are to uphold the ancestral rainforest plant medicine ceremonies as they were transmitted and taught to us, which is a sound and safeguarded method. Likewise, a woman's menstruation is already a process going through Mother Nature's natural and powerful monthly cleanse. Aya is also a powerful cleanse. Both Aya and menses have an abundance of bright light energies challenging to the woman and others in ceremony. Therefore, we ask women to abstain from ceremony until her cycle is over. Thank you for understanding.
AGREEMENTS: I have fully read and understood the contra-indications, mentioned in the web page on foods and drugs to avoid, and I understand the potential implications of using certain pharmaceuticals with MAO-I's. I understand that these are strongly contra-indicated with rainforest plant medicines, and can be very dangerous and potentially fatal when combined. *
Required
I have fully read and agree to practice the Dieta Protocol written up in the following document: https://rainforestmedicine.net/wp-content/uploads/2017/04/DIETA_PROTOCOL.pdf *
Required
I will discontinue all use of alcohol, recreational/street drugs, non-prescribed pharmaceuticals, and contra-indicatory foods such as aged cheese and processed foods, excessive sugar consumption, at least two weeks prior to coming to a Rainforest Medicine Council. *
Required
I have completed this questionnaire myself, have answered truthfully, and have not withheld or misrepresented any information. *
Required
If any new information arises which will affect or change this application, I will communicate this update to the council coordinator via email. *
Required
Is there anything that you like to add to this application for us to better understand where you are coming from? *
Your answer
I release the facilitator, organizer and any/all people associated with Rainforest Medicine Councils from all actions, claims, demands or damages that may result from my participation. *
Required
dahlia miller Please type your name (electronic signature) *
Your answer
Jan. 31, 2019 *
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A copy of your responses will be emailed to the address you provided.
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