Inscription_retreat_form – Hatun Tayta Wasi

ETHNOBOTANICAL THERAPEUTIC RETREAT

Please fill in the form below and send it to us:

Have you had or do you have any illness? When? Which type?

Have you had any surgery? When? What type?

Are you taking any conventional or allopathic medicine? Which? For how long?

Have you ever been in psychotherapeutic treatment? For how long?

Do you take drugs? How often? What type?

What are your eating habits?

Do you regularly drink alcohol? What amount?

Do you play any sport? What kind? How often?

Have you had Teacher Plants before? How often? Where at?

How was your meeting and contact with these teacher plants?

What is the main reason for making this ethnobotanical retreat with Teacher Plants ?

Have you been vaccinated against COVID-19? When?

Did you have any reaction to the COVID-19 vaccine? If so, please tell us about it.

I Declare:

I have not used drugs 72 hours before the retreat and I’m not taking any of the drugs listed below;

I have been correctly informed of the activities carried out in this session;

I have decided to participate in this retreat voluntarily;

I do not suffer from any physical or psychiatric illness diagnosed by professionals;

I will not retire from the retreat venue without the permission of those responsible, and if I do, I release them from any further liability;

I authorize the processing of my personal data to be used only for this retreat. It is according Law 196 of 30/06/2003;

I have read, I understand and I accept the information about the psychotherapeutic approach of work to be done in this retreat;

I am responsible for the decisions I make in my private life after participating in this retreat;

I will not use devices to capture images or videos of the venue or the events taking place.

The following drugs or compounds are not suitable to use combined with Teacher Plants:

IMAO (any antidepressants drugs)
Alcohol
Antihistamines, medication for colds, sinus problems, hay fever or allergies (Benadryl, Benylin, Chlor-Trimeton, Compoz, etc.)
Antipsychotics
Appetite-suppressant pills
Amphetamines
Antihypertensive drugs (for high blood pressure)
CNS drugs (for the Central Nervous System)
ISRS (any selective serotonin reuptake inhibitor)
Medication for asthma, bronchitis or other respiratory problems.

Drugs and Herbs that should be avoided

Actifed (chlorpheniramine and phenylephrine)
Symmetrel (Amantadine hydrochloride)
Amoxapine (Asendin)
Benadryl
Benylin
Bupropion (Wellbutrin)
Buspiron (BuSpar, Ansial, Ansitec)
Carbamazepine (Tegretol, Epitol)
Chlorphenacemide (Chlor-Trimeton)
Clomipramine (Anafranil)
Cocaine
Cyclobenzaprine (Flexeril)
Cyclizine (Marezine)
Desipramine (Petrofrane)
Dextrometorphan (DXM)
Disopyramide (Norpace)
Doxepin (Sinequan)
Ephedra
Ephedrine
Flavoxate hydrochloride
Fluoxetine (Prozac)
Ginseng (Panax quinquefolius, L. or Panax Gingseng)
Imipramine (Tofranil)
Isocarboxazid (Marplan)
Kava Root (Piper methysticum)
Levodopa (Dopar, Larodopa)
Loratadine (Claritin)
Maprotiline (Ludiomil)
Meperidine (Demerol)
Metilfenidato (Ritalin)
Nortriptiline (Aventyl)
Oxybutynin chloride (Ditropan)
Orphenadrine (Norflex)
Parnate Paroxetina (Paxil)
Promethazine (Phenergan)
Phenelzine (Nardil)
Procainamide (Pronestyl)
Protriptyline (Vivactil)
Pseudoephedrine
Quinidine (Quinidex)
Salbutamol
Salmeterol
Selegiline (Eldepryl)
Sertraline (Zoloft)
Sinicuichi (Heimia salicifolia)
St. John’s Woart (Hypericum perforatum)
Tegretol
Temaril-P
Tranylcypromine (Parnate)
Tricyclic antidepressants (Amitriptyline, Elavil)
Trimipramine (Surmontil)
Yohimbine (Pausinystalia Johimbe)

Data Protection:

Under the General Data Protection Regulation EU 2016/679, we have a legal duty to protect any information we collect from you. Information contained in this form and any communication between you and Hatun Tayta Wasi / Casa del Abuelo may be privileged or confidential and intended for the exclusive use of the original recipient, considering exceptions below.
Hatun Tayta Wasi / Casa del Abuelo reserves the right to retain data to the extent required to meet any medical and regulatory obligations, and to any other extent considered reasonable.
Hatun Tayta Wasi / Casa del Abuelo reserves the right to disclose data in the context of the subject needing medical assistance or to comply with any legal or legal and regulatory obligations.
If you would like to update your data or any of the information we might have collected related to you, please inform us by e-mail: info@hatuntaytawasi.com

House of Healing and Ethnobotanical Research

House of Healing and Ethnobotanical Research

ETHNOBOTANICAL THERAPEUTIC RETREAT

The following drugs or compounds are not suitable to use combined with Teacher Plants:

Data Protection:

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