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Select a Kambo Retreat Select a Kambo RetreatKambo Small group | € 99 p.p.Kambo Private | € 250 p.p.Kambo Special Edition | € 450 p.p.

Select a date you want to apply Select a date you want to applySat 15 Mei | Time: 11:00-13:00uSat 20 Mei | Time: 11:00-13:00uSat 27 Mei | Time: 11:00-13:00uSat 5 Jun| Time: 11:00-13:00uSat 12 Jun | Time: 11:00-13:00uSat 23 Jun 2019Sat 23 Jun 2019

Describe why you would like to participate in an Kambo ceremony.

Do you have any experience with Kambo or other entheogenic agents? Do you have any experience with Kambo or other entheogenic agents? Yes No

What kind of entheogenic? What kind of entheogenic? Kambo Ayahuasca San Pedro Paddo's / Truffels Other

What other kind of entheogenic?

Did you have a pleasant experience with the entheogenic? Did you have a pleasant experience with the entheogenic? Yes No

Give a short description why you had a non pleasant experience

Are you being treated or have you been treated by a psychologist / psychiatrist, doctor or therapist? Are you being treated or have you been treated by a psychologist / psychiatrist, doctor or therapist? Yes No

What kind of treatment did you have? What kind of treatment did you have? Psychologist Psychiatrist Doctor Therapist Other

What other treatment did you have?

Describe the handling of your complaints ( max 200 characters)

Do yo have any health condition now or in the past? Do yo have any health condition now or in the past? Yes No

Please select a health condition that applies to you, now or in the past. Please select a health condition that applies to you, now or in the past. Heart attack Cardiac surgery High or Low blood pressure Diabetic Epileptic attacks Cancer Asthma Have had a stroke / risk Blood clots Other

Other, What other diseases do you have?

Please describe your current state of health here in a few sentences. ( max 100 tekens)

Have you ever undergone major surgery? Have you ever undergone major surgery? Yes No

What type of surgery and when was this? 


Do yo have any mental health condition now or in the past? Do yo have any mental health condition now or in the past? Yes No

Please select a mental condition that applies to you, now or in the past. Please select a mental condition that applies to you, now or in the past. Schizophrenia Psychosis / Psychotic attacks Borderline personality disorder Obsessive compulsive disorder OCD Eating Disorder ADHD / ADD Chronic anxiety / Panic attacks Suicidal behavior / ideology Multiple personality disorder Post Traumatic Stress Disorder PTSD Self mutilation Autism Other

What other mental illness did you have

Describe when and for how long?

How much alcohol do you consume per week? How much alcohol do you consume per week? None 1-4 glasses per week 5-7 glasses per week More than 8 glasses per week

Do you use addictive hard or soft drugs? Do you use addictive hard or soft drugs? Marijuana Cocaine XTC/MDMA Painkillers Speed Other

What other drugs do you use on a regular basis?

Do you have other addictions? ( Not required) Do you have other addictions? ( Not required) Yes No

What kind of other addictions?

Are you currently taking antidepressants and / or other medicines at the moment (or last month)? * Are you currently taking antidepressants and / or other medicines at the moment (or last month)? * Yes No

Are you using natural supplements (eg St John's wort, 5 HTP or Kava) at this time (or last month)? * Are you using natural supplements (eg St John's wort, 5 HTP or Kava) at this time (or last month)? * Yes No

I have read the 'FAQ' & 'General Conditions' and am aware of what is expected of me. I understood the intake and completed it truthfully. Hereby I take full responsibility for participating in the ceremony. I am fully aware of what this means. I will not invoke any liability to the facilitators or to Spirit of the Jaguar. When I ruin the ceremony because I do not follow the rules or other participants make it impossible to experience their ceremony, I take full responsibility to compensate Spirit of the Jaguar. Thus approved and signed, understood and approved. * I have read the 'FAQ' & 'General Conditions' and am aware of what is expected of me. I understood the intake and completed it truthfully. Hereby I take full responsibility for participating in the ceremony. I am fully aware of what this means. I will not invoke any liability to the facilitators or to Spirit of the Jaguar. When I ruin the ceremony because I do not follow the rules or other participants make it impossible to experience their ceremony, I take full responsibility to compensate Spirit of the Jaguar. Thus approved and signed, understood and approved. * Yes, i fully understand & i agree