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Intake
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Program
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Room
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Add-ons
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Review
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Payment

Begin Your Intake

This questionnaire helps us ensure your safety and readiness. Your answers are held in confidence.

Personal Information
First name*
Last name*
Phone number*
Email*
How old are you?*
What is your gender?
Emergency Contact
Emergency contact — full name*
Emergency contact — phone number*
Relationship to your emergency contact
Retreat Details
Retreat start date*
Intentions & Background
Describe your reasons for attending a retreat with Soltara. Share what you hope to heal or learn from. Mention any traumas or experiences you hope to address.*
Who would you reach out to for support post-retreat?*
Have you ever experienced any psychedelic substances such as Ayahuasca, Psilocybin, or LSD?*
How many alcoholic drinks do you consume per week?*
Have you ever identified and/or been diagnosed as having an addiction of any kind (e.g. drugs, alcohol, sex, gambling)?*
Are you currently pregnant?*
Medical History
Summarize your medical history, current and chronic conditions, impact on life, and management.*
Have you ever been hospitalized?
Do you have any comfort or mobility needs?
Do you have any allergies?*
Are you currently using any medications (prescription or over the counter) or supplements?*
Describe your mental health status, including self or professionally diagnosed challenges.*
Have you or anyone in your family ever been diagnosed with schizophrenia, bipolar disorder, or experienced psychosis or a related condition?*
Have you ever been trained and/or deployed into active military duty?*
Did you experience any significant traumas through your childhood or adult years?*
Is there any further information about your physical, mental, or emotional health you feel may be relevant?
Previous Experience
Have you ever attended or applied for a retreat at Soltara before?*
Agreements & Acknowledgements
Each person's experience of the medicine is unique; I may not experience visions or strong effects from the medicine. Being open to how the medicine shows up for me is an important part of the experience.*
I agree that I will not take any additional prescription or over the counter medications that I have not disclosed here, prior to my retreat (i.e. cold medicine, antibiotics, etc). I confirm that if circumstances require me to take any additional medications, that I will reach out to intake@soltara.co before I take them. I understand that taking any additional medications may prevent me from participating in ceremony, and that Soltara is not liable for consequences including inability to participate in ceremonies because of this.*
I will not use alcohol or psychotropic substances (including other plant medicines, drugs, and prescription medications) during the retreat. If I have any such substances with me, I agree to turn them in at the beginning of the retreat, where they will be kept safely for me until the end of the retreat. I understand that failure to abide by these policies puts my health and safety at risk and will result in being asked to leave the retreat immediately without refund.*
Drinking ayahuasca can bring up painful and difficult memories, thoughts, emotions, and body sensations into my conscious experience.*
I understand working with ayahuasca is hard work, and requires a deep level of commitment and responsibility. I agree to cooperate with the program, be considerate and respectful of the Shipibo tradition, the Maestros, Soltara staff, and other guests.*
I understand that drinking the Ayahuasca brew and any medicinal plant treatments is not a substitute for professional medical, psychiatric, or psychotherapeutic treatment, but that it may complement a therapeutic process and facilitate spiritual communion, self-development, and personal enrichment. I understand that Soltara is not providing healthcare or medical treatment, nor attempting to diagnose, treat, prevent, or cure any physical, mental, or emotional issue.*
During ceremonies the facilitation team will determine my placement in the maloca to support my own process, typically placing friends, family or partners apart from each other.*
I confirm that the information I have provided above is factual and complete. I understand that any dishonesty or omission of relevant medical or psychological information, either past or present, puts my health, safety, and life at risk, as well as the health and safety of others and the healing container. I understand that I may be held legally and financially liable for any damages incurred due to withholding of relevant medical or psychological information. I confirm that I will reach out to a Soltara team member if any additional relevant information presents itself.*