Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Which ones of the following medicines have you worked with before? *

Uní (ayahuasca)

Rumê (rapéh/ tobacco snuff)

Sananga (eye drops)

Kambô (frog medicine)

none of the above

Do you receive any current treatments? *

Physical, Medical, Psychological

Yes

No

Smoking and drinking *

Do you smoke or drink alcohol?

I do not smoke or drink in a recreational way.

I smoke sometimes (once a week or less)

I smoke frequently (more than once a week)

I drink alcohol sometimes (less than once a week)

I drink alcohol frequently (more than once a week)

I drink alcohol very frequently (more than 3 times a week)