Regenerative Shamanism retreat – 9 day 4 San Pedro ceremonies and 2 Optional Kambo ceremonies

* These fields are required

1 Participant details

2 Welcome

3 Optional Items

Iridology Report

$150.00

Continue

4 Participant Info

Birth Date *

Gender *

Nationality

Passport number *

Occupation

Phone (including country code)

Street Address *

City / Town / Suburb *

State / Region *

Zipcode

Country *

Emergency Contact Name *

Emergency contact - relationship to you *

Emergency contact - Phone, including country code *

Emergency contact - Email *

Continue

5 Medical Screen

Important:

The use of plant medicines is contraindicated with certain medical conditions and medications. Your safety and well-being are our primary concern. In order to ensure this, it is important that you disclose all relevant medical conditions that you have been diagnosed with or experience, as well as all medications, supplements or drugs you are currently taking or have taken in the past. All information you provide is confidential and is collected to assess risk and ensure that you are properly prepared for the sacred plant retreat.

* I understand and agree

Have you been diagnosed with or do you experience any of the following: *
Diabetes
Physical disability
Mobility issues
Epilepsy / Seizures
Dizziness, fainting or blackouts
Autoimmune condition
Thyroid condition
Pulmonary (lung) problems
Asthma
Obesity
Infectious diseases
Hernia
Chronic pain
None of the above

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Do you experience, have a history of or have you been diagnosed with any of the following: *
Bipolar Disorder
Schizophrenia
Dissociative Identity Disorder (DID)
Psychotic episode(s)
Borderline Personality Disorder (BPD)
ADD / ADHD
Anxiety
Panic attacks or Panic disorder
Phobias
Obsessive Compulsive Disorder (OCD)
Depersonalisation / Derealisation
Excessive rumination or worry
Persistent agitation or unease
Depression
Suicidal thoughts or ideation
Cutting or self harm
Persistent low mood or lethargy
Eating disorder
Alcohol or Drug addiction
Chronic insomnia
Paranoia
Uncontrollable rage / anger
None of the above

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Do you experience, have a history of or have you been diagnosed with any of the following: *
Angina
High Blood Pressure
Heart disease
Heart attack
Heart surgery, including stent or pacemaker
Abnormal heartbeat
Stroke
Aneurysm
Breathlessness without exertion
Chest pain or discomfort with exertion
None of the above

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Do you have any serious or life threatening allergies? *
Yes
No

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Do these allergies require the use of an Epipen?
Yes
No

If 'Yes' please confirm that you will be bringing an Epipen with you to the retreat
Yes
No

Have you sustained any recent injuries? *
Yes
No

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Have you had any surgeries or major accidents that you haven’t already mentioned? *
Yes
No

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Have you experienced a significant trauma? (ie abuse, attack, violence, accident, loss of a loved one) *
Yes
No

If so please provide details. * If not applicable please write 'NA'

Are you Pregnant? *
Yes
No
Not applicable

Do you have any other medical or health conditions not listed above? *
Yes
No

If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). * If not applicable please write 'NA’.

Do you have a family medical history of any of the following? *
Diabetes
Epilepsy / Seizures
Dizziness, fainting or blackouts
Autoimmune condition
Thyroid condition
Pulmonary (lung) problems
Asthma
Obesity
Infectious diseases
Hernia
Chronic pain
Bipolar
Schizophrenia
Dissociative Identity Disorder (DID)
Psychotic episode(s)
Borderline Personality Disorder (BPD)
ADD / ADHD
Anxiety
Panic attacks or Panic disorder
Obsessive Compulsive Disorder (OCD)
Depersonalisation / Derealisation
Depression
Self harm
Alcohol and drug addiction
Paranoia
Uncontrollable Rage / Anger
Angina
High Blood Pressure
Heart Attack
Heart Disease
Heart Surgery
Abnormal heartbeat
Stroke
Aneurysm
No I do not

If so please provide details. * If not applicable please write 'NA'

Continue

6 Medications, Supplements and Drugs

Please list any pharmaceutical medications you are currently taking including dosage, frequency and time you take them. * If not applicable please write 'NA'

Please list any pharmaceutical medications you have taken in the past, how long you took them for and when you stopped taking them. * If not applicable please write 'NA'

Please list any herb, vitamins or supplements you are currently taking or have taken in the past month. * If not applicable please write 'NA'

Please list any recreational drugs you currently use and how often you use them. * If not applicable please write 'NA'

Please list any recreational drugs you have used in the past, how long you used them for and when you stopped using them. * If not applicable please write 'NA'

Continue

7 Acknowledgement

Important:
I understand that Samadi Healing has collected this information for the express purpose of assessing risk and optimising my safety and well-being. I attest that I have fully and truthfully disclosed all requested medical information and facts. I further understand that by omitting or falsifying relevant information I may be putting myself at risk and accept full responsibility for my actions.

* I understand and agree

Continue

8 Plant Medicine Experience

Have you used plant medicines in the past? (Ayahuasca, Psilocybin mushrooms, Peyote, San Pedro etc. *
Yes
No

If so where, when, with whom and on how many occasions?

What were the results?

What is your primary motivation for ingesting sacred plants?
Physical healing
Psychological healing
Emotional healing
Behavioural change
Personal growth and development
Spiritual exploration
Personal exploration

Is there anything else you would like us to know about yourself or your reasons for ingesting sacred plants?

Continue

9 Accomodation

If you've elected to share a room with a friend or partner please provide their name

Continue

10 Food

Do you have any food allergies, intolerances or preferences you’d like is to know about?
Yes
No

If so please provide details

Continue

11 Restrictions and Guidelines

Important:
Sacred plants can have a powerful impact on your body and mind.

In the days and weeks before the retreat, during the retreat and after the retreat certain restrictions need to be observed. Adhering to these restrictions will ensure your safety and wellbeing, as well as a positive sacred plant experience.

Drugs and Alcohol
Recreational drugs and alcohol are prohibited for 14 days before the retreat, during the retreat and for 7 days after the day of your last ceremony. Please be informed that consuming alcohol or recreational drugs directly following a plant medicine ceremony or retreat can be extremely dangerous, and can potentially lead to psychological problems.

Sex
Sex or sexual activities of any kind (including masturbation) are not permitted during the retreat and for 3 days after the day of your last ceremony.

Medications and supplements
There are certain pharmaceutical medications that are contraindicated for sacred plants and our shaman will discuss these with you. You are not permitted to take these medications prior to the retreat, during the retreat, and for at least 3 days after the day of your last ceremony. If you need to take any new medications in the 3 days following the ceremony, please contact us to ensure they are compatible with San Pedro. The use of vitamins and minerals after the retreat is permitted.

Sugar
You should not consume processed sugar, sugar-laden foods or artificial sweeteners for 3 full days before the retreat, during the retreat and for 3 days after the day of your last ceremony. Fruits and fruit juices are acceptable in moderation.

Meat
Do not consume meats that might contain violent or skittish energies for at least 14 full days before the first day of the retreat. Examples include: Rabbit, Pork, Deer, Aligator, Pirana, Shark, and Duck.
___________________________

The reasons for these restrictions will be explained to you by one of our staff members at the commencement of the retreat. Should you have any questions or concerns please don't hesitate to discuss them with us.)

* I have read and understood the guidelines and restrictions and agree to abide by them.

Continue

12 Referral

How did you hear about us? *
From a friend or retreat participant
Web search
Facebook or Other social media

Friend or participant's name

After your registration, you will be directed to book a discovery call with us. This step is part of your registration process. Please choose a time and date for your call where we can meet each other in person and go over your registration form to cover any necessary questions. *
I understand and agree

Continue

13 Donate

Please enter your donation amounts below

$
Support more by donating
A big part of the income at Samadi Healing is being accumulated to support the creation of a healing center. Your donation is contributing to manifesting this dream.

Continue

14 Payment

Sub Total $0

Taxes $0

50% Deposit $0

Pay Choose to pay a deposit or the full amount right now.

Due Now $0 $0

Security Check

You will be asked for credit card details in the next step.
Click the button below to continue.

Continue

Retreat Guru is the online booking agent for Samadi Healing.

Charges will appear on your bill as "Retreat Guru"

Regenerative Shamanism retreat - 9 day 4 San Pedro ceremonies and 2 Optional Kambo ceremonies - in the Sacred Valley, Peru. Mar 10, 2025

1 Participant details

2 Welcome

3 Optional Items

4 Participant Info

5 Medical Screen

6 Medications, Supplements and Drugs

7 Acknowledgement

8 Plant Medicine Experience

9 Accomodation

10 Food

11 Restrictions and Guidelines

12 Referral

13 Donate

14 Payment