Consultation Form

Personal Details

Full Name *

Date of birth

Occupation

Phone *

Country

Emergency Contact Name *

Emergency Contact Number *

Relationship Status

Do you have children?

Are you pregnant? *

Preparation

By completing this foundational section, you will gain further insight and clarity around why we here at Meraya believe you are your greatest investment. You will also gain clarity around your current thoughts, feelings, strengths, desires, as well as that which may be hindering you to fully show up. Through awakening and direct focus you can recognize that, which no longer serves, May this section inspire you further on why the plant teachers may be the perfect fit for the liberation you seek.

What are your top three reasons for participating in a healing retreat, plant dieta, or studies at Meraya? Please list them in order of importance, with #1 being your primary reason. Examples: Trauma recovery, addiction healing, forming plant spirit connections, self-empowerment, facilitating retreats, learning indigenous healing practices, or other personal goals.

1
2
3

What is the maximum amount of time you are able to dedicate to an in-person healing retreat or plant dieta? Please specify the duration in days, weeks, or months.

Have you ever taken part in any extended spiritual, silent, meditation, or psychedelic retreats? If so, please share any challenges you faced and strengths you discovered during these experiences.

What is most important to you when considering a spiritual retreat? Please describe in detail the key factors that influence your decision, such as personal goals, the retreat environment, facilitator expertise, or any other considerations.

What potential challenges or distractions do you foresee that might prevent you from being fully present and open during your dieta or retreat? Examples could include concerns about finances, loved ones, unresolved memories, or family issues. Please share in detail.

If you feel comfortable, please share a bit about your life journey so far. You may share as much or as little as you’d like. For example, you might describe your childhood, religious background, emotional experiences, what brings you joy or causes you to withdraw, and where you feel most connected or disconnected. Additionally, if there are any areas of trauma you'd like to address during this course or retreat - such as sexual, physical, or emotional abuse - please feel free to include them.

If you could change anything about your current life, what would it be? Please provide a list of the aspects you would like to transform or improve.

What are your top three goals that you aim to achieve in the next year? Please list them in order of priority.

1
2
3

Why are these goals a must?

What are the top 3 things preventing you from achieving those goals?

1
2
3

How would your life change if the three obstacles to your goals were removed? Please describe what that vision looks like for you.

How would you describe your understanding of and connection to Spirit, God, or the Universe? Please share your insights and feelings regarding this relationship.

What qualities do you value most in yourself? Please explain in detail why these qualities are important to you and how they influence your life.

What are your intentions for participating in a plant dieta, healing retreat, or educational course? Please describe your goals and what you hope to achieve through this experience.

What is your vision for what you hope to gain upon completing your plant dieta, healing retreat, or educational course? Please share your aspirations and the outcomes you envision from this experience.

Is there any additional information we should be aware of, such as learning difficulties, specific conditions or requirements? Please share any details that may be relevant to your participation.

Medical Screening

It’s very important to answer all questions honestly and disclose of all health conditions, the plant spirits will discern if you are suitable for our retreats or courses, let’s not confuse any decision in this process. This form is completely confidential and will only be shared with our small team of space holders. We will notify you as soon as we check through the information if you are successful in gaining a place within our retreats or educational courses.

Please list all physical health conditions present, past and any diagnosis? (Please put N/A if not applicable) *

Please list all mental health or psychological conditions present, past and any diagnosis? (Please put N/A if not applicable) *

Has anyone in your family suffered with any metal health conditions? (Please put N/A if not applicable) *

List all prescribed medications you have ever taken? *

Are you currently taking any medication, pharmaceutical or herbal drugs? (Please put N/A if not applicable) *

Are you allergic to any medicines? *

When was the last time you took any medicine, what was it and please provide dates? (Please put N/A if not applicable) *

Have you ever taken any psychedelics please make a list? (Please put N/A if not applicable) *

Have you ever taken illegal drugs if so please and make a list? (Please put N/A if not applicable) *

Have you ever suffered with addiction, with drugs, food, consumerism please explain and make a list? (Please put N/A if not applicable) *

Dietary Requirements

Which of the following best describes your diet type?

Omnivore (Red meat and fish as a meat source)

Pescetarian (Fish only as a meat source)

Vegetarian (No meat or fish; will eat eggs, milk and cheese)

Vegan (Strictly no animal products

Do you have any food allergies? *

The dieta retreats involve consuming very little food, typically one meal per day. We have found that being in a state of ketosis facilitates the deepest connection to the dieta, resulting in reduced resistance to inner healing and an expanded consciousness. As with all aspects of our courses and retreats, this is a guideline designed to help you maximize your experience. If you have any specific needs or circumstances outside of these guidelines, we can discuss them to ensure a harmonious experience during your chosen dieta or healing retreat.

Declaration

I will discontinue all use of alcohol, marijuana, recreational/street drugs and non-prescribed pharmaceuticals at least two weeks prior to coming to Meraya and at least 7 days before any online training event. I understand that these are strongly contraindicated with Ayahuasca and can be very dangerous and potentially fatal when combined. I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca. I have read, understand and will comply with Meraya’s medical guidelines, declaration, liability agreement and all terms and conditions. I take full responsibility and liability in my free choice to take any plant medicines.

Please electronically sign below *

Clear

Please date here *

Step 1

Step 2

Step 2