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First Name
*
Name
Last Name
*
Surname
Email
*
Email
Phone Number
*
Phone number
Address
*
Your permanent address
Birthday
*
Let us know your age
I want to do a retreat in
*
Valencia - Spain
Albufeira - Portugal
Please choose your location
Preferred Retreat Dates
*
When would you like to join our retreat?
Have you or any of your family members experienced any of the following: psychosis/bipolar disorder/borderline/schizophrenia/mania/delusions/severe anxiety/severe depression/suicidal ideation? If yes, which ones, when and under what circumstances?
*
Mental health history
Do you have a heart condition or high blood pressure?
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Yes
No
Tell us about your health
Which medications are you taking on a regular basis?
*
Tell us about your health
Previous experience with Ayahuasca or other psychedelics
*
Previous experience with Ayahuasca or other psychedelics
Do you agree to refrain from drinking alcohol for at least one week prior to the retreat?
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No
Yes
Your safety
I agree to the terms and conditions of Vine of the Soul Retreats
No
Yes
I agree to follow the dietary guideline for 2 weeks before the retreat
*
No
Yes
Your safety
Please Please tell us about your motivation for participating in this retreat
*
Your motivation
Any allergies or special dietary requriements?
*
Your allergies and food preferences
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