Contact

First Name:

Last Name:

Email Address:

Phone Number:

Please give a brief medical history and describe any current health conditions:

Please list current medications and supplements:

Do you currently have or had in the past any of the following conditions: Stroke, Brain Aneurysm, Brain Hemorrhage, Blood Clots, Addison's Disease, Epilepsy, Chemotherapy, Medication for Low Blood Pressure, Recovering from a Major Medical Procedure, Major Mental Health Disorders (excludin Depression and PTSD), Pregnant (or may be pregnant)? If so, please list which and when you experienced:

What lead you to the medicine?

What is your intention for this ceremony? What are you looking for from this experience?

What was your childhood like? (Caretakers, feelings, thoughts, experiences):

What are your close relationships like? (Friendships, spouse, coworkers):

How badly do you want things in your life to change?(1-10) What changes do you want to see? How do you want to feel?

Do you have tools that you can use before, during, and after ceremony? Ie. Meditation, yoga, prayer, journaling, etc.: