Have you participated before in any program of Reborn?

(if so please select the most recent one).

Are you under any treatment with antidepressants, anxiolytics, or have you been under any type of treatment related to mental health in the last 6 months?

If you answered yes to the previous question,

please share the medication, dosage and

frequencies as well as your doctor's diagnosis

and the symptoms you experience.

If you answer NO, write Not Applicable.

Have you had any experience with psychotropics, whether in recreational, therapeutic or ceremonial formats?

If yes, please share with us relevant aspects of your experience and if you had any trip that you consider negative for your process. 

Do you suffer or have you suffered from any mental illness or have you been diagnosed with any psychiatric condition?

If you answered Yes, please specify dates, context, treatment,

length of the treatment, casues (if identifyable)

and results/changes after the treatment.

If you answered No please write Not Applicable.

Do you suffer from Glaucoma, any serious cardiovascular disease or any terminal illness?

If you answered Yes to the previous answer, please share details of your treatment, (dates, lenghts, medications, etc...). Please be as detailed as possible.

If you answered No, but you have other milder cardiovascular conditions, such as hypertension, blood pressure issues, or any other controlled condition, please disclose as many details as possible.

If you don't have any background of cardiovascular conditions, write Not Applicable.

IMPORTANT: We may ask participants for further studies or information such as electrocardiograms, blood pressure test or blood tests to assure participant's safety. If you have been recently (last 12 months) tested in any of these fields, please let us know.

Have you received any psychological, holistic or energetic therapy in order to work on your emotional, psychological state or life process? If yes, please share with us the type of therapy, and the time you have been taking it or that you took it. 

If you have any other medical condition, please disclose diagnosis, symptoms, treatment and length of the treatment. Please let us know any past condition as well. Every detail is essential to your safety.

Describe the reasons why you want to participate in this program/experience.

I declare that the information presented in this Safety Sheet is true, and unless expressly stated otherwise: 

- I do not use neuro-psychiatric medications, antidepressants such as selective serotonin reuptake inhibitors or oxidase inhibitors (MAOIs).

 - I don't use anticonvulsants/anti-seizures medications.

- I have no history of psychotic episodes or psychiatric hospitalization.

- I know the direct and indirect risks of working with psychotropic drugs as well as the consequences of not disclosing all the information that is requested of me.

In consideration of the foregoing, in this act I agree that I waive any claim, demand or action of any kind that I could claim personally or through any representative, including in this waiver, but not limited to, exercising actions in against "Feel Reborn", José Antonio Casas-Alatriste Parlange and José Martín Arce Balbuena (hereinafter referred to as "Feel Reborn") and/or the facilitators, co-facilitators, associates, representatives, guides, therapists, agents, employees and any other who had participated in the work program with psychotropics, for damages, injuries, suffering, moral damages, punitive damages and in general any inconvenience resulting from my participation in the work program with psychotropics. Due to the foregoing, from this moment I grant the most extensive settlement in favor of "Feel Reborn", José Antonio Casas-Alatriste Parlange, José Martín Arce Balbuena, and the aforementioned third parties for any inconvenience, damages, suffered by me and /or my assets and belongings due to the work program with psychotropic drugs.

I consent and authorize that my sensitive personal data, such as data related to my present and future health status, relevant medical history, mental illnesses (including diagnoses and treatments), information related to the use of medications and/or depressant substances, stimulants and/or, religious and/or philosophical beliefs, are treated by "Feel Reborn" in accordance with the provisions of the Privacy Notice that is available on the website whose electronic address is https://privacidad.l2f.me, which I have read, reviewed and consented to.

I have carefully read this document and fully understand its content and legal scope. I agree to hold harmless "Feel Reborn" and/or partners, associates, representatives, guides, therapists, agents, employees and any other related to them, for which I sign in accordance: