Intake Questionnaire — On the Toltec Way

Section 1

Personal Information

Basic details so we can match your form to your registration.

First name *

Last name *

Email *

Phone (with country code)

Age

Gender / Pronoun

Occupation / Vocation

Languages you speak

Which retreat(s) are you registered for?

Niños Santos — Oct 23–28, Chemuyil, Mexico Bufo × Peyote — Oct 28–Nov 2, Chemuyil, Mexico Molecule of God — Switzerland, TBD

How did you hear about this retreat?

Section 2

Medical History

Important: Use of certain medications can be contraindicated with the medicines used in ceremony — particularly SSRIs, MAOIs, and lithium. Please be accurate and complete here. Your safety depends on it.

General physical health Rate from 1 (poor) to 5 (excellent)

Please describe any medical conditions furtherSeverity, duration, whether currently under care

Have you had any major accidents? Describe if so.

Any hospitalisations or surgery? Describe if so.

Any history of head injury?

Family history of aneurysms?

Section 3

Mental Health & Emotional History

Overall mental health Rate from 1 (struggling) to 5 (flourishing)

Which of the following apply to you?

Depression Anxiety Post-Traumatic Stress Disorder Substance use disorder or addiction Obsessive compulsive disorder Bipolar disorder Personality disorder Schizophrenia or psychotic episodes None of the above

Please describe your substance use history

Are you currently taking medication for bipolar disorder?This is critical for safety — certain medications are contraindicated.

A history of schizophrenia or psychotic episodes is a significant contraindication. Please discuss with us directly before completing this form.

Please describe any psychiatric condition or mental health struggle furtherInclude any hospitalisations and dates

Have you ever experienced physical, verbal, emotional, or sexual abuse?At what age? You may be brief or detailed — whatever feels right.

Have you ever had thoughts of suicide or self-harm?

Briefly describe your experience with each of the following How often, how intensely, how it affects daily life

Anxiety

Depression

Feeling helpless

Feeling lonely

Stress or nervousness

Any other traumas worth mentioning

Section 4

Medications & Supplements

SSRIs, MAOIs, lithium, antipsychotics, and many other medications are contraindicated. If in doubt, list it. Include dose, frequency, reason, and duration.

Current medicationse.g. Sertraline 50mg daily for anxiety, 2 years. Or: none.

Supplements, herbal products, or over-the-counter products

Section 5

Lifestyle

Do you have difficulty trusting others or life? How often do you experience fear or paranoia?

Substances you use Select all that apply, then describe below

Describe your use of any substances listed aboveType, frequency, quantity, duration. Be honest with yourself.

Spiritual practice or personal development approach

Physical activity and exercise

Describe your typical daily dietBe honest — it matters for how the medicine works.

Your current living and social situation

Quality of interpersonal relationships — any ongoing struggles?

Section 6

Inner Resources

Your beliefs around love

Self-care practices — how do you nurture yourself?

How do you typically cope with difficulty or adversity?

Your beliefs around death

Current professional or formal support Therapist, psychiatrist, counsellor, alternative practitioners — how often do you see them?

Is there someone you trust who knows about this work?What is their disposition toward you pursuing it?

What practices will help you integrate this experience?

Section 7

Psychedelic & Ceremonial History

Have you tried psychedelic substances?

Yes No — this will be my first experience

What substances, in what context?e.g. Peyote twice ceremonially. LSD recreationally many times. Ayahuasca 3 times. Breathwork.

Have you had a difficult or challenging psychedelic experience?

Impact of previous experiences on your life

Welcome. This being your first experience is something we will explore carefully together in your preparation call. Please be especially thorough in your responses throughout this form.

Any concerns about the upcoming experience?

Section 8

Intentions

What is your intention for this retreat?Take your time with this one. Not what you expect — what you are moving toward.

The top 3 things you hope to gain from this work

The top 3 things you hope to let go of or leave behind

Anything else you would like us to know before we meet?

Section 9

Emergency Contacts

Two trusted people we may contact if needed during or after the retreat.

Contact 1 — name, relationship, phone number

Contact 2 — name, relationship, phone number

Section 10

Agreement & Waiver

Please read through carefully, then confirm your agreement below.

I understand that accurate reporting of the above information is necessary to help ensure a safe and beneficial experience. I have answered this form truthfully to the best of my ability.

I am responsible for my own health and understand that participation in this event may pose risks. To the best of my knowledge, I am in good physical and mental condition. In the event of a medical emergency, I agree to seek appropriate care.

In consideration of being allowed to participate, I hereby release, waive, and discharge the event's leaders, organizers, hosts, and participants from any and all liability, claims, or demands arising out of or related to any loss, damage, or injury — including death — that may be sustained by me while participating in this event or while on the premises where the event is conducted.

I voluntarily assume full responsibility for any risk of loss, property damage, or personal injury, including death, that may result from the event's activities.

I acknowledge that I have read and understood this waiver, that I am at least 18 years of age, and I execute this release fully intending to be bound by it. This waiver applies to all present and future work with this event's leadership.

I have read and agree to the above waiver. I am 18 years of age or older. *