Please copy and paste this Application to a document or email & send your application to:
We will review and response within 24 hours to 4 weeks depending on our Ceremony Availability.
Basic Health Background Check
ALL information is STRICTLY confidential, and will not be shared with anyone. Christine is our Spiritual Administrator & is the only person, other than our Head Shaman, who reviews our applications and has access to your information for safety purposes only.
1. IF you take medication to treat or control a diagnosis, it MUST be listed here. NONE is to be used ONLY if you have NO medical issues or problems. OTHER is for ALL diagnoses and problems not listed here. This information is for YOUR history only, NOT FAMILY.
History of Heart Disease
History of Heart Problems
History of Chronic High Blood Pressure
History of Depression
History of Anxiety
History of Mental Health Disorder (ex. PTSD, Bi-Polar Disorder, Borderline Personality Disorder, etc..)
History of Psychosis
Taking SSRI's or SNRI's
Taking St. John's Wart
OTHER (for diagnoses/problems NOT listed here)
None (use ONLY if you have NO medical conditions)
2. Please list WHEN, WHERE, AND WITH WHAT you were diagnosed. If it is a SELF DIAGNOSIS, list it is a self diagnosis AS WELL as WHEN the diagnosis was made. N/A is acceptable here ONLY if "NONE" was checked on the Health Background.
3. If you checked History Of Mental Health Disorder, please list WHAT the History of Mental Health Disorder Diagnosis is as well as WHEN AND WHERE it was diagnosed. If it is self diagnosed, please list that as well as why you believe you have this Disorder. N/A is applicable here ONLY if you did not check History of Mental Health Disorder in the Health History Background:
4. IF you checked High Blood Pressure, you need to list NUMERICALLY what your blood pressure runs BOTH on AND off your medication/
5. If you checked "OTHER", please list what the "OTHER" is as well as WHEN AND WHERE it was diagnosed. If it is a self diagnosis, that needs to be listed. N/A is applicable ONLY if "OTHER" was NOT checked on the health background:
6. If you checked for addiction, are you clean?
Please list the specific drugs:
IF you are not clean, how long can you stay clean prior to Ceremony?
7. Are you currently taking any medications either prescribed or over the counter?
8. Please list all medications you are taking:
What are the medications prescribed for?
9. Are you sensitive to medication and medicine?
Have you ever used psychoactive substances/hallucinogens?
If you have, what was your last experience like?
10. Emergency contact information:
We will not be contacting this person unless necessary during ceremony.
11. What are you seeking to achieve as a member of Cosmic Valley Native America’s Church?
12. Which Ayahuasca Ceremony Date where you interested in joining?
13. Where did you hear about our Ayahuasca Ceremonies? (Facebook, Instagram, Website, Word Of Mouth, etc.)
14. Lastly, we will need some of your basic information.
City & State:
Date of Birth:
ALL information is STRICTLY confidential, and will not be shared with anyone. Our head shaman is the only person who reviews applications and has access to your information for safety purposes only.
Electronic Signature-By signing here I affirm that all of the information given on this application is true and accurate. I also affirm that I understand that upon attending a ceremony (should my application be accepted) that I will be signing a Waiver of Liability; that I understand that there is potential risk (however low it may be) and that I release Cosmic Valley from any and all liability, that I am doing this at my own risk
Please be aware that after you’re approval, we require you purchased a Lifetime Membership prior to joining a Ceremony.
Thank You & Namaste