Name
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First Name
Last Name
Email
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Nationality
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Birthday
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Emergency Contact Name
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First Name
Last Name
Emergency Contact Number
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Country
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Date of Arrival
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What treatment are you interested in?
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Select all that apply.
Have you drunk ayahuasca before?
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Do you have expperience with other visionary plants or psychadelics? Please explain.
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Physical and mental health history
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It is necessary that you agree to disclose, in confidence, any known medical conditions and/or use of any medication. By coming to Casa de Pawua, you are declaring that you are in a physical and mental condition appropriate to the activities described in the treatments, and agree that you participate at your own risk and that we cannot accept liability for any accident or injury. You should seek professional medical advice on preparations. We need to offer this advice and insist on these conditions in order to assure your personal safety and the overall safety and welfare of our patients and team.
Although ayahuasca has not been found to cause psychosis or other psychiatric disturbances, it can be dangerous to those with a history of psychological problems. Please tell us, in confidence, about any history of mental health problems. If you have a heart condition or chronic high blood pressure you may not be able to drink ayahuasca. It is not safe to drink ayahuasca when you are pregnant. Special note to diabetics: MAOIs may change the amount of insulin or oral anti-diabetic medication that you need. If you are diabetic or have high blood pressure please provide more information in the section "Is there anything else about your physical or mental health we should know about?" for us to closer discuss your particular case. There is a chance that you may not be able to drink ayahuasca but instead receive treatment from other plants focused on treating these conditions.
Please indicate if any of the following conditions apply to you:
If selected "other", please explain.
Are you currently pregnant?
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Please indicate if any of the following pertain to you.
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- Have you ever been hospitalized for medical or psychiatric reasons?
- Do you have any history whatsoever of psychosis, schizophrenia, hallucinations, or bipolar diagnosis?
- Are you currently in therapy or involved in any type of support group?
If your answer is “yes” to any of the above, please elaborate.
Is there anything else about your mental, physical or emotional health that we should be aware of?
Medication history
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Certain drugs and medications have been found to not be compatible with ayahuasca. It is essential to stop taking the following substances, and give your system sufficient time to remove them from the body, before you begin a treatment with us. Please consult your doctor if you are in any doubts, you certainly should not suddenly stop taking prescribed medications (including antidepressants) without consulting your doctor.It is not safe to work with ayahuasca if you take the following medications or have any of the following health conditions: any medication that contains Monoamine oxidase inhibitors (MAOI’s). These medications are known to cause dangerous side effects when taken in conjunction with ayahuasca. It is critical that you stop taking these drugs and allow plenty of time for your system to be cleared of these substances. Any medication which has an effect on the serotonin system, including Selective Serotonin Reuptake Inhibitors (SSRIs) (i.e. antidepressants such as Wellbutrin, Prozac, Zoloft, Effexor, etc). Combining these medications with ayahuasca can induce serotonin syndrome – far more severely than with foods containing tryptophan, and with potentially fatal results. We advise you to stop taking SSRI medications four weeks prior to a program to allow the system to clear in time; some of these drugs may cause side effects when you stop taking them, and you should allow plenty of time for these to subside. You should not abruptly stop taking them without discussing the matter with your doctor. Please note that the herbal antidepressant St. John’s Wort (Hypericum Perforatum) also must not be taken directly prior to working with ayahuasca, although the system can clear this in 2 weeks before commencing a retreat. Other medications you must suspend taking are decongestants, cold medications, allergy medications, antihistamines, sedatives, tranquillizers, amphetamines (including Adderall), some hypertensive medications, sympathomimetic amines including pseudoephedrine and ephedrine, carbamazipine, methylphemidate (Ritalin), macromerine, phenelanine, tyrosine, tryptophan, asarone/calamus, asthma inhalers and diet pills.For the next four questions, please note that it is imperative that you provide an accurate and detailed list of medications, supplements and recreational drug intake as the plant medicine can dramatically increase the effects of certain substances to the point of becoming dangerous. Please note that all medications will need to be discontinued prior to arriving at Casa de Pawua for treatment with plant medicine, and if applicable, we recommend seeking advice from your doctor how to taper off medication safely.
Are you currently taking ANY type of pharmaceutical medications, over-the-counter medication, prescription medication, vitamins, herbs or supplements?
Please also indicate if you have ever taken tranquilizing medications, SSRIs or any other antidepressant medication?
If “yes” to any of the above, please list all medications including dosage and frequency taken and for how long.
List any recreational substances that you have taken over the past 12 months (alcohol, "street drugs"). Please include frequency of use.
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To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.
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Terms and conditions.
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Bookings are made on the understanding that you (and your group members if relevant to this booking) will abide by these terms and conditions.
“The Organiser” Raul Mascaya Mocho of “Casa de Pawua” and his agents, staff and assistants.
“The Patient" is the person named on the Booking Form for this program. Where this is a group leader making a booking on behalf of a group of individuals the term “Patient” also includes all members of the group leader’s party and the leader agrees to accept responsibility for them.
1. The Organisers reserve the right to accept or decline a Patient booking at any time.
2. The Patient agrees to take part in a program offered at Casa de Pawua.
3. The Organisers will do their utmost to ensure the safety and comfort of the Patient within the remit of this program. The Patient, in turn, agrees to exercise caution and consideration for him or herself and for others during this program, including at the venue and in other environments, and indemnifies the Organiser against claims for injury, loss, damage, misadventure or inconvenience at all stages.
4. The Patient has made confidential disclosures regarding medical conditions and/or use of medications. The Organizer agrees to keep these in confidence unless required by law to divulge them and/or for the resolution of any dispute. The Patient agrees to inform the Organizer of any change in circumstances.
5. The Organizer have recommended that the Patient, prior to entry into this Agreement, seeks and obtains health or medical advice as to the effect of plants and herbal medicines singly and in combination with any medication they are taking. The Patient avows that he or she, having done so or deemed it unnecessary, is in a physical and mental condition appropriate to the activities described on the website and agrees to participate at his or her own risk. The responsibility for taking accurate and timely health precautions, professional medical advice, and for acting upon this (or otherwise) is solely with the Patient.
6. The Patient has the option of joining any, all, or none of the activities offered within the program booked at Casa de Pawua and taking any, all or none of the plants available, and should he or she wish to take them does so voluntarily, taking full responsibility for his or her actions.
7. The Patient has been advised that ayahuasca is a visionary plant that includes changes in bodily sensations and that ayahuasca and tobacco may involve a purge and is clear on the meaning of this. The Patient confirms they have conducted research where appropriate to satisfy him or herself of the effects that may be produced. The liability is with the Patient.
8. The Organizer is not responsible for travel or other costs outside of this program or for flight cancellations or other interruptions or travel disruptions and no refunds, reimbursements or payments-in-kind will be made for these.
9. The Organizer reserves the right to make changes to the itinerary or costs of this program if necessary or to cancel the program if need be. In the unlikely event that the program is cancelled a full refund will be made to the Patient of fees paid by him or her to the Organizer. The Organizer is not, however, responsible for other costs which the Patient may incur or have incurred such as transportation or the purchase of any goods or materials.
10. The Organizer will do his best to help with any special requests or needs that the Patient may make or have but are not beholden to do so and the Patient understands that such requests may need to be paid for by the Patient separately to this program and its contents and that he or she may also have to make his or her own arrangements (e.g. for travel outside the program) and at his or her own cost.
11. The Patient will not hold the Organizer liable for damages, injuries, losses, accidents or delays, including willful or negligent acts, failures to act or breaches of contract by any parties which supply goods or services for this treatment program.
12. The Patient indemnifies the Organizer against loss or damage, including that resulting from insufficient or improperly issued passports, visas or other travel documents.
13. The Patient has been advised to take out suitable medical and travel insurance for their journey and this event, covering personal accident, medical expenses, losses, repatriation costs and all other expenses which might arise as a result of loss, damage, injury, delay or inconvenience. Group leaders must also ensure that they have adequate public liability insurance to cover themselves and their group in case of accidents or other misfortunes. The Organizer is not liable for such expenses
14. The Patient - and his or her family – understand that the Amazon rainforest and this program represent travel of a unique nature and will hold the Organizer and its associates, representatives and employees blameless for any injury or ailment occurring during this program or afterwards.
15. The Patient agrees to show respect for the environment he or she is in and to act with courtesy and dignity toward other group members and local and native people at Casa de Pawua. Should the Patient commit any illegal act or should his or her behavior adversely affect other people’s enjoyment of this treatment program he or she may be asked to leave the Center and shall have no entitlement to complaint or refund and will bear any expenses as a result of this.
16. The Patient agrees that any photographs, videos, film or notes taken by the Organizer during this treatment program in which the Patient may feature may be published by the Organizer and gives consent to this without consideration unless prior written agreements are entered into.
17. The Patient agrees to acknowledge Casa de Pawua and this program (including email and website addresses) in any production of his or her own which may result from his or her participation in this treatment program, whether this is of a commercial or non-commercial nature. This may include but is not limited to books, articles, films, videos, CDs, tapes, DVDs and productions using on-line resources such as YouTube and Facebook which are intended or available for public broadcast or diffusion. Such acknowledgement must not, however, be presented as an endorsement by the Organizer of any materials produced by the Patient unless this is expressly agreed in writing.
18. The relationship between the Patient and the Organizer is governed by Bolivian law and in the unlikely event that a controversy arises which cannot be resolved between us both parties agree to the exclusive jurisdiction of the Bolivian Courts in La Paz, Bolivia.
19. The Patient has read, understood and voluntarily accepted this document and agrees that no representations, statements or inducements have been made by the Organiser for him/her to take part in this program or to accept this Agreement. By accepting the Patient waives certain legal rights, including the right to sue.
Agreement of policies and guidelines
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By coming to Casa de Pawua, all guests agree to the following policies, guidelines and waivers:
- Patient understands that no returns or refunds are available once payment has been made for any reason.
- Patients voluntarily enter into a shamanic treatment with Maestro Nino, which may include a series of plant-based treatments including Ayahuasca
- No patient will be forced, coerced or pressured into taking Ayahuasca or any other treatment they are not comfortable with.
- Patient agrees to cease any supplemental treatment during their period of stay at Casa de Pawua, and follow Maestro Nino’s recommended protocol to the best of their ability.
- Patient understands that Casa de Pawua makes no claim or guarantee of healing or curing, and patient releases Casa de Pawua from responsibility (legal and otherwise) of any and all adverse effects guest may experience.
- It is the patient's responsibility to adequately research plant-based shamanic treatment, including Ayahuasca, and fully read and follow Casa de Pawua's Preparation and Medical Precautions pages.
- Patient agrees to fully disclose any addictions, psychiatric diagnoses, communicable diseases, special needs and other relevant medical history.
- All personal information that the patient discloses to Casa de Pawua will be kept confidential and will only be shared with relevant Casa de Pawua staff.
- Patient agrees to honor and respect all Ashaninka traditions introduced at Casa de Pawua and refrain from attempting to change or disparage these traditions when communicating with other guests.
I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly in the "Patient Registration" form which includes: "Contact information", "Plant medicine experience", "Physical and mental health" and "Medication history" and have not withheld any information. I also confirm that I have read, understood, and accept the "Patient Agreement" and "Terms & Conditions."
Add your full name in the field below to indicate your agreement.
