3-Day Ancestral Ayahuasca Retreat with the Palchukán Family

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What intention are you bringing into this experience, and what areas of your life are you seeking to heal, transform, or gain clarity around?
Do you experience any of these symptoms? (Headache, Faintness, Dizziness, Smoking, Tightness in Jaw, Arthritis, Carpal tunnel syndrome, Insomnia, Pain in the body, Indigestion, Loose bowel movements) *
Select any areas below that you would like improvement in: (Examples: Negative self talk/ Self Sabotage, Belief in ability to achieve goals, Procrastination, Ability to reach ideal weight, Finding purpose?, Strengthen memory and concentration, Breaking old habits, Self Esteem, Vitality, Financial position?)
Have you experienced any personal, emotional, or physical hardship that has impacted your ability to function in daily life?Have you experienced any personal, emotional, or physical hardship that has impacted your ability to function in daily life?
Medical Issues	Enter "none" if you have no issues
Are you currently managing any form of addiction (e.g., compulsive spending, substance dependency, pornography addiction) or experiencing mental health challenges? If so, please elaborate on any pertinent information of which we should be aware at this time. *
Do you currently experience or have a history of any of the following conditions: Tumors, Other Implants, Metal Implants, Screws, Heart conditions, Diabetes, Stroke, High or Low blood pressure, Phobias, or Epilepsy? *
Have you recently experienced any mental health concerns? If so, please elaborate: *
Have you had any previous experience with holistic ceremonies or energy healing modalities? If the answer is yes, describe your experience or experiences. *
Do you feel anxiety, or fall into states of depression? *
Is there a family history of schizophrenia, bipolar disorder, or any other psychotic disorder? *
Are you currently taking any prescription or non-prescription medications? This includes pharmaceutical and plant-based medicines. Please specify the duration for which they have been taken. *
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Are you undergoing any form of physical or emotional pain at the moment? If so, please include what and where. *
Terms and Conditions *	I accept the terms and conditions.Please read the terms and conditions
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: Plant Medicine. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

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$	Santuario Retreats Support the preservation of our sacred land in Antioquia, Colombia. Your donation helps us maintain the natural sanctuary, fund social projects and retreats, and keep this healing space accessible to all.
$	Child Liberation Foundation Help us protect and empower children in vulnerable communities. Your contribution funds education, safe spaces, and trauma recovery programs for kids who need it most. Learn more at https://childliberation.org/

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Guest 1		First Name* Last Name* Email*
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