Ayahuasca Ceremony Intake Form
Ayahuasca Ceremony Intake Form
Comprehensive medical and psychological screening for participants attending a traditional ayahuasca ceremony.
Participant Information
Full legal name *
Your answer
Date of birth
Phone
Emergency contact
Your answer
Medical Screening
Are you currently taking SSRIs, SNRIs, MAOIs, or other antidepressants?
+ 13 more questions
About this template
Comprehensive medical and psychological screening for participants attending a traditional ayahuasca ceremony.
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