Participant Intake Survey

Thank you for your interest in joining us in a healing ceremony!

We are honored to have the opportunity to assist you on your path. Please take the time to read these questions and answer carefully. If you prefer not to answer a question, please leave it blank.

Please reach out with any questions or concerns. We will review this form carefully and contact you for additional information or to confirm that you are eligible to attend.

You are not eligible to participate in a healing ceremony if; you are under the age of 18, you have a history of psychosis. schizophrenia, or bipolar disorder, history of seizures or diagnosis of epilepsy, experienced a stroke or severe cardiovascular disease, uncontrolled high blood pressure.

For health and safety reasons you cannot attend a healing ceremony if at the time of the retreat you are taking SSRIs or MAO-Is, recreational drugs, or have taken any medication or supplements 24 hours prior to the ceremony.

I have read the conditions above and: *

Yes, I agree with the conditions above

No, I do not agree with the conditions above

Which ceremony are you applying for?

Please select one or multiple options.

April 25 - Tucson, AZ - SIngle Night ($275)

April 26 - Tucson, AZ - SIngle Night ($275)

April 25 & 26 - Tucson, AZ - Both Nights ($500)

Legal Name - First and Last *

Preferred Name (if different)

Date of birth *

Email *

Phone *

City and State of residence (enter Country if outside the U.S.) *

Are you serving or have you served in any branch of the armed forces of the United States? *

Yes

Do you take any medications, herbs, or supplements? *

Yes

If yes, please list any medications, herbs, or supplements being taken:

Are you able to stop the use of medications, herbs, and supplements prior to ceremony? *

Yes

If not, please explain why you are unable to stop taking medications:

Do you have any current health conditions or recent illnesses? *

Yes

If yes, please explain current health conditions or recent illness:

Do you have any proior health conditions? *

Yes

If yes, please explain prior health conditions:

Are you currently pregnant? *

Yes

How is your mental health? Please list any concerns, both diagnosed and undiagnosed. *

Have you ever been hospitalized for any psychiatric issue? *

Yes

If yes, please describe any prior hospitalizations:

Do you have a current or history of substance abuse issues? *

Yes

If yes, please describe any current or history of substance abuse:

What are your intentions for attending a healing ceremony? *

What would you like to gain from this experience? *

Are there any trauma triggers you would like us to be aware of (touching, tight spaces, loud noises, etc.)? *

Yes

If yes, please describe those trauma triggers:

Have you previously attended a healing ceremony or worked with consciousness-altering states? *

Yes

If yes, please describe prior ceremony experience:

Do you have a meditation, shamanic, or other spiritual practice? *

Yes

If yes, please describe your spiritual practice:

Do you have an adverse reaction to tobacco, sage, or smoke in general? *

Yes

If yes, please describe your reaction to tobacco, sage, or smoke:

Do you have any food restrictions or allergies? *

Yes

If yes, please explain and indicate if allergy or preference:

Signature and Agreement page.

The above is true and correct to the best of my understanding. I realize that failure to disclose information pertinent to my physical and psychological health could result in harm to me and fellow participants.

In consideration of being allowed to participate in this event. I hereby release, waive, discharge and covenant not to sue the event leaders, organizers, crew members, homeowner, and participants from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted. To the best of my knowledge, I am in good physical condition and I am not aware of any physical and psychological infirmity, which would place me at risk to participate in any way with the ceremony activities.

By signing below, I am acknowledging that I have carefully read this document and fully understand the terms and conditions of this liability waiver statement & in voluntarily; I am at least 18 years of age and fully competent; and I execute this release for full, adequate and complete considerations fully intending to be bound by the same.

I have read completely, understand and: *

Yes, I do agree to the terms of the statement

No, I do not agree to the terms of the statement