My Medical Information – Two Birds Church

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Personal Contact

Name(Required)

First Last

Gender(Required)

Male

Female

Other

We assign sleeping arrangements by gender. If you select “Other,” you will stay in the ceremony room, as private rooms are not available.

Birth Date(Required)

YYYY

Must be 18 years or older to join us in ceremony.

Email(Required)

Please enter a valid email as we may send notifications on availability to this address

Phone(Required)

Please enter a valid number as we may send notifications on availability to this number

Please list your location (City,State) you are traveling from(Required)

City State

How did you discovery Two Birds Church?(Required)

Ex. Google Search, Facebook, Instagram, Reddit, Safeceremonies.com, Word of mouth etc.)

Have you attended any Sunday Services, Outreach, or Virtual Services?(Required)

Are you an active member of the Church?

Emergency Contact

This person may be contacted if there is a medical or safety concern during your stay.

Emergency Contact Name(Required)

First Last

Please provide someone we can contact if there is a medical or safety concern during your stay.

Emergency Contact Phone(Required)

Please provide a number where they can be reached during your ceremony weekend.

Relationship(Required)

Example: Spouse, parent, sibling, friend

Emergency Contact Name(Required)

First Last

Please provide someone we can contact if there is a medical or safety concern during your stay.

Emergency Contact Phone(Required)

Please provide a number where they can be reached during your ceremony weekend.

Relationship(Required)

Example: Spouse, parent, sibling, friend

Mental Health History

Have you ever been hospitalized for mental health reasons?(Required)

This includes voluntary or involuntary psychiatric holds, inpatient treatment, or stays in a mental health facility.

Yes

Please describe your mental health hospitalization(s)(Required)

When did this occur? What was the reason? How long were you hospitalized? What treatment did you receive? Are you currently stable?

Have you ever experienced any of the following?(Required)

(Check all that apply)

Psychosis (losing touch with reality)

Hallucinations (seeing or hearing things others don’t)

Paranoid episodes (believing others are trying to harm you)

Dissociative episodes (feeling disconnected from yourself or reality)

Manic episodes (periods of extremely elevated mood, energy, or risky behavior)

None of the above

Please describe your experience with psychosis, hallucinations, paranoia, dissociation, or mania(Required)

When did this occur? Was it related to substance use or medication? How was it treated? Are you currently stable?

Have you ever had thoughts of harming yourself?(Required)

Please answer honestly. Having struggles does not automatically disqualify you.

Yes, currently

Yes, in the past but not currently

No, never

Please describe your experience with thoughts of self-harm(Required)

When did this occur? What was happening in your life at that time? Did you receive support or treatment? How are you doing now?

Have you ever had thoughts of harming others?(Required)

Please answer honestly. This is about safety for everyone in the space.

Yes, currently

Yes, in the past but not currently

No, never

Please describe your experience with thoughts of harming others(Required)

When did this occur? What were the circumstances? Did you receive treatment or work through this? What is your relationship with those thoughts now?

Are you currently in a mental health crisis or acute emotional distress?(Required)

Ayahuasca is not crisis intervention. If you are in acute crisis, we recommend stabilizing with professional support before attending ceremony.

Yes

I’m not sure

VIOLENCE AND SAFETY HISTORY

Have you experienced any of the following?(Required)

Please answer honestly. A past history does not automatically disqualify you, but we need to understand your background. Ayahuasca can bring up intense emotions and we need to know if you have patterns around aggression

Arrested or charged with a violent crime

Physically harmed another person outside of self-defense

History of aggressive behavior when under stress, intoxicated, or in altered states

None of the above

Please describe your history with violence or aggression(Required)

What happened? When? What were the circumstances? Have you addressed this through therapy, treatment, or other means? How do you manage stress now?

CURRENT LIFE CIRCUMSTANCES

Are you currently going through any of the following life circumstances?(Required)

Ceremony during acute life crisis is possible but requires honest assessment of your readiness.

Recent death of a loved one (within 6 months)

Divorce or relationship ending

Job loss or financial crisis

Legal troubles

Other major life transition causing significant stress

None of the above

Please describe your current life stressors(Required)

What are you going through? How are you coping? Do you feel stable enough to enter ceremony, or are you hoping ceremony will fix the crisis?

How would you describe your current mental and emotional state?(Required)

Be honest with yourself and with us. There is no judgment—only a desire to support you safely.

Stable and grounded

Mostly stable with some challenges

Struggling but managing

In crisis or significant distress

MILITARY SERVICE

Have you ever served in the military?(Required)

We welcome veterans. This information helps us understand your background and support you appropriately.

Yes

Please describe your military service(Required)

Branch, years of service, whether you were deployed to a combat zone, and whether you have been diagnosed with or treated for combat-related PTSD or TBI.

Ceremony

Have you done a Ceremony before?(Required)

This helps us understand your experience level and tailor our support accordingly. If you’ve sat with us before, welcome back. If you’re new to Two Birds but have experience elsewhere, we’ll ask about that next.

Yes

Please describe your previous ceremony experience(Required)

If you’ve sat with us before: How was your experience? Anything we should know going into this ceremony? If you’ve sat elsewhere: Where did you sit? How many times? How did it go? Why are you looking for a new space?

Do you have any experience with other plant sacraments?(Required)

Please provide details if yes. What substances? How many times? Ceremonial or recreational? How did you respond?

What is bringing you to ceremony at this specific time in your life?(Required)

We want to understand not just what you hope to experience, but why NOW feels like the right time. What has led you to this moment? What are you hoping to meet or release?

Please tell us a little about your Intention for Ceremony(Required)

What do you hope to meet, understand, or release? This isn’t about having the “right” answer – it’s about being honest with yourself about what you’re seeking.

Medical

Are you currently using any recreational substances?(Required)

This includes alcohol, cannabis, nicotine/vaping, psychedelics, MDMA, cocaine, or any other substances. This is about current use and timing for ceremony preparation, not judgment.

Yes

Please describe your current substance use(Required)

What substances? How often? When did you last use? Are you prepared to abstain for the required dieta period before ceremony?

Have you ever had a traumatic brain injury (TBI), concussion, or significant head injury?(Required)

This includes injuries from car accidents, sports, falls, combat, assaults, or any significant impact to the head—even if it seemed minor at the time.

Yes

Please describe your head injury(Required)

When did it occur? What caused it? Did you lose consciousness? Do you have any ongoing symptoms such as headaches, memory issues, mood changes, or confusion?

Are you currently pregnant?(Required)

Ayahuasca is not safe during pregnancy. If you are pregnant or think you may be, please select Yes so we can discuss this with you before registration.

Yes

Not Applicable

Have you ever been diagnosed with any of the following?(Required)

Please answer honestly. A diagnosis does not automatically disqualify you.

Depression

Anxiety

PTSD

Bipolar disorder

Schizophrenia or schizoaffective disorder

Borderline personality disorder

Other mental health diagnosis

None of the above

Please describe your mental health diagnosis(Required)

When were you diagnosed? Are you currently in treatment? Are you stable? How does it affect your daily life now?

Do you now, or have you ever had a dependency on any of the following?(Required)

This includes past dependencies, even if you are now in recovery.

Alcohol

Prescription medications

Opioids or painkillers

Stimulants (cocaine, meth, adderall)

Cannabis

Other substances

None of the above

Please describe your experience with dependency(Required)

What substance(s)? Are you currently using or in recovery? How long sober/clean if applicable? Are you in a program or receiving support?

Do you have any food allergies we should be aware of when preparing meals?(Required)

Please list any food allergies, dietary restrictions, or preferences. We prepare meals during your stay and want to accommodate your needs. Type “None” if no restrictions.

Are you currently taking any prescription medications, supplements, or recreational drugs.(Required)

This is critical for your safety. Some medications have dangerous interactions with ayahuasca, including antidepressants, SSRIs, MAOIs, blood pressure medications, and others. Please answer honestly – we will review this with you before approval.

Yes, I am on medication

No, medications or drugs’

Medications currently taking. (List medications, dosage, and how often you take it please, and reason for taking)(Required)

This is very important. Please be detailed with the name of the medication as well as dosage and frequency. If you are on contraindicated medications it can be seriously fatal. Please be honest.

Health Conditions(Required)

Please list any health conditions such as heart problems, high or low blood pressure, bypass surgery, implants, pacemakers, seizure disorders, diabetes, or any other physical health conditions not covered above. Type “None” if you have no conditions to report.

Individual Participation Agreement(Required)

Ayahuasca is a deeply personal journey that requires full surrender and individual focus. If attending with a friend or partner, we will separate you as much as possible, and interaction will not be permitted during the ceremony.

I understand that this is an individual journey. I feel personally called and fully prepared to navigate this experience on my own, without external reliance or distraction.

Prohibited Items(Required)

Bringing a weapon to ceremony (in a bag, car, or anywhere on the property) will result in immediate removal, permanent ban from all future events, and may be reported to law enforcement. No exceptions.

I understand that weapons of any kind (firearms, knives, etc.) are strictly prohibited and agree not to bring any weapons to the property

Sleeping Arrangement's.(Required)

Men and women will have separate shared bunk rooms for sleeping to ensure everyone’s comfort and safety. There is also an option to sleep in the ceremony room if preferred.

I understand my sleeping arrangements

Transportation(Required)

Please make sure you have your own means of transportation to the retreat and back. If you are flying in, you are responsible for renting a vehicle, Uber, or ride to the retreat center.

I will provide my own transportation to and from the retreat.

Medication Requirements(Required)

I understand I will need to be off All contradicting medications prior to my ceremony.

Yes, I understand the medication requirements

Medical Disqualification(Required)

I understand that if our medical consultant gives a no-go based on medications, I will be fully refunded. I will wait to make reservations or flights until I receive an OK from the medical consultant at Two Birds. Tickets can not be transferred to other dates or held for future ceremonies.

Yes, I understand the medical disqualification

La Dieta(Required)

I am aware of the Dieta restrictions and will be off any substances the appropriate amount of time to ensure safety (Prescription, Nonprescription, and Recreational drugs including marijuana)

Yes, I am aware of Diet

Bloodpressure(Required)

I agree to have my blood pressure taken before ceremony

Yes, I allow to have my blood pressure taken before ceremony

Safety(Required)

I understand that my Keys & Phone will be locked up for safety before ceremonies and returned the next morning.

Yes, I allow to have my phone & keys taken before ceremonies

Honesty Agreement(Required)

The safety of our ceremonies depends on honest disclosure. Withholding or falsifying information—especially regarding mental health, medications, or safety concerns—puts yourself and others at risk and may result in removal without refund.

I confirm that all information provided on this form is complete and accurate to the best of my knowledge

Refund Policy(Required)

Any cancelations made within 2 weeks of the start date receive a refund minus the Deposit and CC processing fees cancelations made 2 weeks or fewer from start date can not be refunded. Tickets can not be transferred to other dates or held for future ceremonies.

I agree to the refund policy & the nonrefundable deposit and CC Fee

New Member Screening Requirement(Required)

All first-time participants must complete a brief video call or in-person meeting with our team before being approved for ceremony. This is a conversation to ensure this is the right fit for both of us.

I understand and agree to complete a new member screening before my registration is confirmed.

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Medical Consultation notes

This is for notes from Dr Ben.