Retreat Intake & Health Waiver

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Weight & Height?

Are you pregnant or breastfeeding?

Are you currently under the care of a physician?

Please list two Emergency contacts:

Do you have a diagnosed heart condition

Do you have any known allergies, (including food , plants, medication, insect) ?

If so, are you taking medication? Please list

Do you have a history of Seizure or been diagnosed with a seizure disorder ?

If so, are you on medication , if so please list all medications

Have you been diagnosed with Depression, Anxiety, Schixophrenia , Multiple Personality Disorder or Bipolar?

Are you currently on any SSRI's if so please list all

Are you currently taking any medications (prescriptions or over the counter? If yes, please list all

Do you have a history of addiction, Alcohol, Cocaine ,Methamphetamine, etc?

Are you currently taking any psychotropic drugs, including plant derived?

Are you currently consuming Energy Drinks Dietary supplements Appetite Suppressants

Do you consume caffeine on a daily basis? If so how many cups?

How do you feel your mental state is at this current moment?

Have you had suicidal thoughts, if so when?

What do you wish to change in your world and around you?

Have you had previous Entheogenic Journey's? If so how was that experience for you?

Are you willing to follow a Dieta for this retreat?

Do you commit to respect confidentiality when it comes to this retreat.

Can you commit to 3 total integration calls?

Do you commit to following all guidelines from your medicine woman, Jaime and her team?

If at any given moment you would like to express yourself, regarding needs or concerns, can you feel comfortable speaking directly to Jaime and her team?

Intentional practice is so important, please share what your intentions are for this upcoming retreat.

Acknowledgements

By signing below, I acknowledge and agree to the following:

I understand that I am voluntarily participating in a sacred plant medicine ceremony, which may include substances such as [insert plant medicines used, e.g., cacao, hapé, psilocybin, etc.], and that these medicines have both physical and psychological effects.
I have disclosed all relevant medical conditions, allergies, and medications to the facilitator(s). I understand that failure to disclose accurate information could put my health at risk.
I acknowledge that the ceremony and related services are not a substitute for medical or psychiatric care, and the facilitators are not licensed medical professionals unless explicitly stated.
I understand that I am fully responsible for my own physical, emotional, and spiritual well-being before, during, and after the ceremony.
I agree not to hold Ayana Spirit Medicine Sanctuary, its facilitators, volunteers, or guardians liable for any injury, illness, or adverse effects resulting from my participation in this ceremony.

Consent

I have read and understood the information above. I have had the opportunity to ask questions and receive answers. I voluntarily agree to participate and accept full responsibility for my experience.

Date

Month

Day

Year

Signature

Health Waiver& Consent for Treatment

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Emergency Contact

Are you currently under the care of a physician?

Yes

If yes, physicians name and phone number.

Do you have a history of seizures or a seizure disorder ?

Do you have any diagnosed heart conditions?

Acknowledgment and Assumption of Risk

I acknowledge that I have voluntarily chosen to participate in shamanic healing services, ceremonies, or related activities offered by Ayana Spirit Medicine Sanctuary (“the Sanctuary”). I understand that these activities may involve emotional, physical, mental, and spiritual processes that can sometimes be intense and unpredictable.

I am aware that participation may carry certain risks, including but not limited to physical exertion, emotional release, or psychological discomfort. I knowingly and voluntarily accept full responsibility for any risk of injury, loss, or death arising from my participation.

Non-Medical Services Disclaimer

I understand that the services provided are not a substitute for professional medical, psychological, or psychiatric care. I affirm that I am responsible for seeking any necessary professional care and that I will inform the Sanctuary of any health concerns prior to participation.

Personal Responsibility

I certify that I am physically, mentally, and emotionally capable of participating. I agree to honor my own boundaries, to participate to the extent that feels safe for me, and to immediately inform the facilitator if I experience discomfort or need assistance.

Release of Liability

In consideration of being permitted to participate, I, for myself, my heirs, executors, and assigns, hereby fully release, indemnify, and hold harmless Ayana Spirit Medicine Sanctuary, its facilitators, owners, agents, employees, and volunteers from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury that may be sustained by me.

Confidentiality and Respect

I agree to respect the confidentiality of other participants and to hold sacred the shared experience within the Sanctuary community. I understand that the space is held with the utmost integrity and that mutual respect is expected.

Photography & Media Release (Optional)

I grant permission to Ayana Spirit Medicine Sanctuary to use photographs or recordings taken during events for promotional or educational purposes unless otherwise indicated in writing.

Acknowledgment of Understanding

I have read this Waiver and Release of Liability in full. I fully understand its terms and acknowledge that I am signing it freely and voluntarily.

Signature:

Our Privacy Policy

Privacy Policy

Ayana Spirit Medicine Sanctuary

Effective Date: 4/24/2025

Ayana Spirit Medicine Sanctuary (“we,” “our,” or “us”) is committed to protecting the privacy and personal information of all clients, participants, and visitors. This Privacy Policy outlines how we collect, use, store, and protect your information in alignment with the sacred and confidential nature of the services we provide.

1. Information We Collect

We may collect the following types of personal information:

Full name, address, phone number, email
Emergency contact details
Medical history and relevant health information (only as provided voluntarily)
Intake and consent forms
Payment and transaction information
Feedback, testimonials, or inquiries you share with us

2. How We Use Your Information

We use your information for the following purposes:

To safely and ethically guide you through ceremonies, sessions, and healing modalities
To maintain records for internal and legal purposes
To contact you regarding your appointments, follow-ups, or service updates
To enhance our offerings and improve the quality of our services
To honor your preferences and spiritual needs

3. Information Sharing and Disclosure

We do not sell, rent, or trade your personal information. Your information will only be shared:

With your explicit consent
If required by law or legal obligation
In a medical emergency, with appropriate professionals, when necessary for your safety

4. Confidentiality of Ceremony and Sessions

All personal experiences shared during sessions and ceremonies are held in strict confidence. We uphold a strong spiritual and ethical boundary to ensure your trust and privacy are protected.

5. Data Security

We implement physical, administrative, and digital safeguards to protect your information from unauthorized access, disclosure, or misuse.

6. Your Rights

You have the right to:

Request access to the personal data we have on file
Request corrections to inaccurate or incomplete data
Request that we delete your information (unless retention is legally required)
Opt out of any future communication at any time

7. Updates to This Policy

We may update this policy from time to time. Any changes will be posted on our website and made available at our sanctuary. Continued use of our services indicates your agreement with the latest version.