Retreat Registration – Kuntanawa Nation

Registration

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Please Select The Retreat You Are Interested In Attending

Full Name *

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Last

Phone Number *

Email Address *

Address *

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City

State / Province / Region

Postal Code

Who Referred You?

Spiritual Practice & Plant Medicine

Do you have a spiritual practice? If so, please describe.*

What Are Your Intentions/Goals For This Retreat

Have you attended a Kuntanawa event previously? *

Is this your first time taking any medicinal plants from the Amazon? *

Medical History

Are you curently receiving medical treatment? *

If yes, please provide details

Do you have any medical conditions? *

Please list the medical conditions below

Medical History: Please mark any of the following conditions with which you have been diagnosed or for which you are receiving treatment. *

NONE
Anorexia
Aspergers
Aids/HIV
Asthma
Aneurysm
Arthritis
Bipolar Disorder
Cancer
Cardiovascular Issues
Chest pains
Chronic pain
Coronary Issues
Coronary Artery Bypass Surgery
Covid 19
Cranial Injuries
Dysrhythmia
Diabetes
Epilepsy
Fibromyalgia
Gynecological
Acute Disease
High blood pressure
Heart Attack
Heart Conditions
Hyperthyroidism
Hypoxia
Infectious Disease
Low Blood Pressure
Lung Conditions
Meningitis
Migraines
Multiple Sclerosis
Neurological Disorders
Obesity
Personality disorders
Pregnancy
Schizophrenia
Stroke
Tuberculosis
Tumor
Ulcers
Other

Please describe any checked answer from above *

Any disabilities or medical conditions not mentioned above? *

Please provide details

Are you currently taking any prescribed or over-the-counter medications, supplements or herbal therapies? *

If yes, please list them all

Herbal Contraindications for some of our medicinal plants:

St. Johns Wort • Kava • Kratom • Ephedra • Ginseng • Yohimbe • Sinicuichi • Rhodiola Rosea • Kanna • Boswellia • Nutmeg • Scotch Broom • Licorice Root

Are you taking any of the above Herbal Contraindications? *

If yes please explain

Do you currently use any recreational drugs or alcohol? *

If yes, please describe below

Cannabis Interactions: Smoking marijuana before drinking some medicinal plants may stupefy and darken the overall experience, acting as a blockage. Given the general amplified sensitivity of all participants during the event, marijuana negatively affects not just the person who used it, but potentially other participants’ experiences as well as the overall energy of the medicine circle. It is important that your system is clear of cannabis for at least 12 hours

I have read, understand and agree to the above statements regarding marijuana? *

Medical Contraindications

Please be as forthcoming as possible when answering the questions above. If any potential medical contraindications are present, we will inquire further to ensure your safety. By registering for a program, you are declaring that you are in physical and mental condition appropriate to the activities described, that you agree to participate at your own risk, and that we cannot accept liability for any accident or injury. We will provide the most secure environment to work with medicinal plants as much as possible and ensure your welfare to the best of our abilities, at all times. In return, we ask that you behave responsibly and do not endanger yourself or others. General Medical Precautions when working with medicinal plants can carry health risks; please disclosure any known medical conditions.

Please contact us before making a reservation to discuss your particular case (e.g. tuberculosis). Although the medicinal plants we use have not been found to cause psychosis or other psychiatric disturbances, it can be dangerous to those with a history of psychological conditions. Please inform us of any history of mental health problems in the past. It is important to suspend any kind of psycho-pharmaceutical and depression treatments 14 to 35 days before drinking some of our medicinal plants. We will provide more specific advice on how to proceed under the supervision of your doctor once we receive details of a particular medication in question.

Contraindications from an Amazonian plant healer’s perspective: When a patient or apprentice is working with a medicinal plant, it is preferable to not take any other substances. This may cause and interference with the plant’s energy and provoke unwanted reactions. Certain drugs and medications have been found to not be compatible with some medicinal plants. It is essential to stop taking the substances listed in this document and give your system sufficient time to remove them from the body before you begin a program. We will provide advice on how to proceed during your booking process. Please consult your doctor if you are in any doubt. You should not stop taking prescribed medications without consulting your doctor.

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