Hummingbird Church Participant Intake Form

Please read the information on this page before getting started.

The following form helps us understand a little bit more about you and how we can best ensure that you have a meaningful and safe experience during our sacred healing ceremonies.

Please take into consideration that this is a religious ceremony, not a medical or wellness procedure or facility.

You are required to complete this intake form before you will be eligible to participate in any of our sacred ceremonies.

I have read the statement above *

Yes, I understand and wish to continue

You are not eligible to participate in a sacred healing ceremony if:

You are under the age of 21.

You are in your first trimester of pregnancy.

You have a history of psychosis and or schizophrenia.

You have been diagnosed with a personality disorder.

You currently have active medicated bipolar disorder.

You have a history of seizures or diagnosis of epilepsy.

You currently have anorexia and / or bulimia.

You have ever experienced a stroke or embolism.

You have severe asthma or emphysema.

You have a known cardiac illness.

You have uncontrolled high blood pressure.

You have Crohn disease, irritable bowel syndrome, ulcerative colitis, or intestinal ulcers.

You have had surgery within the last three months on any part of your digestive system.

You currently have liver disease.

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

All of your responses are entirely confidential.

Please read each question and answer carefully.

If you would prefer not to answer a question, please leave it blank.

I have read the above statement *

Yes, I understand and wish to continue

Inappropriate sexual behavior will result in immediate removal from the ceremony.

The top priority of Hummingbird Church is to create a safe space for all participants and staff. Our ceremonies are not a place to hook up with people or engage in sexual activity. Out of respect for the sacredness of our ceremonies and the participants in attendance, we will ask the parties involved in sexual activity to leave the retreat.

We are not referring to your behavior while in ceremony, we are referring to deliberate behavior outside of the actual ceremony. This is a place to heal and commune with God, not a party, or a place to meet singles.

If you meet someone that you have a genuine connection with, we encourage you to engage with them at a more appropriate time, outside of the retreat.

During our retreats participants are in vulnerable states and have their hearts open. We cannot chance predators taking advantage of anyone in this state, so we take excessive touching, massaging, caressing, cuddling, and co-sleeping between participants very serious.

If you are attending with a significant other you can engage in touching, cuddling, caressing, and massage outside of the actual ceremony, we just ask that you refrain from sexual activity during the length of the retreat.

Please do not hit on our staff, trust that the love you feel from them is genuine and platonic. Our staff adheres to a strict code of conduct which requires them to take certain steps if they form a romantic connection with anyone they meet at a retreat.

If you have a true connection with someone, what is true now will be true a month from now. So please respect yourself and all attendees by refraining from any romantic and / or sexual behavior while at our retreats.

I understand that I will be asked to leave the retreat if I am hitting on participants and / or staff, caught engaging in excessive touch with another participant, and / or engaging in sexual activity with myself or another party during the retreat. *

Yes, I understand.

Non-refundable / Non -transferable deposit and No Refund Policy:

Once accepted, your spot will be reserved by making the non-refundable, non-transferable deposit. Final payment for the remaining balance is due two weeks before the retreat starts. If you have made final payment and are unable to attend, we will transfer your amount paid, minus your deposit, to a future retreat. We will not issue a refund as we pay for the retreat well in advance of the actual date.

We understand that unexpected events in life happen and we want to work with you the best that we can, and this policy is it. Our church lost over $10,000 in 2022 from registered participants not showing up, being transferred to multiple retreats, and from no shows demanding refunds and disputing credit card charges. We are a non-profit and any excess funds we receive go directly towards funding scholarships for veterans, first responders, and BIPOC.

Disputing credit card charges and reporting charges as fraudulent activity to your bank and/or credit card will result in you no longer being accepted to attend any future events. This activity is dishonest, and time consuming and costly for us to deal with.

Do not pay the non-refundable, non-transferable deposit unless you fully understand and accept this policy.

I am aware that if I dispute the charges paid to Hummingbird Church, that this affidavit will be sent to my credit card and / or banking institution to serve as proof that I was fully aware of Hummingbird Church's policies regarding deposits and transfers. *

Yes, I have read, understand, and agree to the refund policy.

Demographic Information:

Legal Name - First and Last *

Preferred Name (if different)

Age *

What gender do you most identify with? (This is for the purpose of separating sleeping quarters for men and women) *

Male

Female

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

Ceremony Interest:

* How did you find Hummingbird Church? If referred by someone who has attended please state their first and last name.

Have you ever attended an ayahuasca ceremony before, if so how many times?

Please state the date and location of the last ceremony you attended with Hummingbird Church. Leave blank if not applicable

* Are you able to stop all medication and supplements prior to the retreat? Please consult your treating physician before stopping any medication or treatment plan.

Yes

If No, please explain why you are unable to stop all medications and supplements prior to ceremony.

Motivations and Challenges:

Please briefly state your reasons for seeking to attend a sacred healing retreat with Hummingbird Church: *

What are your current life challenges? *

Are there any trauma triggers that you would like us to be aware of (such as; touching, loud noises, tight spaces, shouting, drumming, high pitched noises, male or female authority, or others)? *

What would you like to gain from this experience? *

About You:

What is your occupation? *

What are your hobbies or interests? *

Who are the most important people in your support network (friends, family, spiritual leaders or community, therapists, etc)? *

Is there any area where your support network is lacking? *

Have you experienced any of the following?

Do you believe in God or a higher power? There is no right or wrong answer here *

Yes, please explain

Explain your beliefs here.

Meditation, consciousness-altering states, or shamanic retreats? *

Yes, please explain

If Yes explain here.

Trauma in childhood? - Only answer if you feel called to share.

Yes, please explain

Explain childhood trauma here.

Trauma as an adult? - Only answer if you feel called to share.

Yes, please explain

Explain adult trauma here.

Significant losses or grief? - Only answer if you feel called to share

Yes, please explain

Explain losses or grief here.

Does your immediate family support your having this experience? *

Yes

No, please explain

Explain family support here.

Do you have any questions or concerns?

Yes, please explain

Explain questions or concerns here.

Do you take any MAO inhibitors? Examples include Marplan, Nardil, Niamid, Parnate, Jatrosom, & Emsam. *

Yes, please describe

Describe here, please state medication name, dosage & frequency:

Do you use any SSRIs (selective serotonin reuptake inhibitor)? Examples include Zoloft, Celexa, Lexapro, Luvox, Paxil, Prozac, Viibryd, & Symbyax. *

Yes, please describe

Describe here, please state medication name, dosage & frequency:

Do you use any NDRIs (norepinephrine-dopamine reuptake inhibitor)? Examples include; Wellbutrin/Bupropion, Cleofil, Amineptine, Focali, & Ethylphenidate. *

Yes, please describe

Please describe, include medication name, dosage & frequency:

Do you take any tricyclic antidepressants? Examples include Anafranil, Tofranil, Vivactil, Nortriptyline, Amitriptyline, Imiprex, and Amoxapine. *

Yes, please describe

Describe here, include medication name, dosage & frequency:

Do you use any amphetamines or "amphetamine-like" medications? Examples include Adderall, Concerta, Ritalin, Phentermine, Evekeo, ProCentra, Dyanavel & Vyvanse. *

Yes, please describe

If Yes, please state medication name, dosage & frequency:

Do you take any narcotic pain killers? Examples include Oxycodone, Vicodin, Codeine, Dilaudid, Duragesic (fentanyl), Demerol, Norco, Lorcet, Methadone & Heroin. *

Yes, please describe

If Yes, please advise of medication name, dosage & frequency:

Do you use an asthma inhaler or take any asthma medications? *

Yes, please describe

Please state asthma medication name, dosage & frequency:

Are you taking any supplements that contain L-tryptophan? *

Yes

Do you have an adverse reaction to tobacco and/or nicotine? *

Yes

Please list any life threatening allergies

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 social or psychological health could result in harm to me and fellow participants and I agree to indemnify and hold harmless Hummingbird Church and their assistants if all relevant information is not disclosed. I also agree to notify Hummingbird Church should there be any changes in my physical, mental or emotional health status. *

I Agree to the above.