Dear Participant, We are grateful for your interest in attending Men's Retreat Peru. In order to ensure the safety and well -being of all attendees, we need to ask you some essential questions about your health and background.

Your answers to these questions will be kept confidential and will only be used to determine your eligibility to attend the retreat. If you have any concerns or questions, please don’t hesitate to contact us.

Name *

First Name

Last Name

Email *

Phone

Have you ever taken plant medicines or psychedelics in the past? If so, please list which ones and how many times.

Have you ever had any adverse reactions to plant medicine or psychedelics in the past?

Yes

Are you currently taking any prescription medication? If yes, please specify.

Have you ever been diagnosed with a mental health conditions such as depression, anxiety, or psychosis?

Yes

Have you ever had a history of alcohol or drug abuse?

Yes

Are you pregnant or trying to become pregnant?

Yes

Do you have any physical disabilities that may affect your participation in the retreat activites?

Yes

Do you have any allergies or dietary restrictions that we should be aware of?

Yes

Are you currently under the care of a physician for any medical conditions?

Yes

Thank you!

JOHN JACOB MUBARAK

T&Cs