Sacred Medicine Session Intake Form

Please complete the below information relevant to your participation in a medicine ceremony. Please note the information provided is fully confidential.

First name

Last name

Do you have a preferred pronoun?

Do you have any previous experience with plant medicines or psychedelics?

Yes

No

If yes please tell me about your experience.

Tell me about you and why you're interested in plant medicine.

Do you now or have you in the past suffered from any psychiatric disorder? Such as depression, anxiety, schizophrenia, bi-polar disorder, multiple personalities, etc?

Yes

No

If yes, please explain.

Are you currently or have you in the past been addicted to alcohol or other substances?

Yes

No

If yes, please provide details.

Do you regularly smoke cigarettes, use cannabis or other recreational substances?

Yes

No

If yes, please give additional details here:

Please list any medications you are currently taking, dosage, and what they are intended to treat.

Please list any medical conditions you have or have had in the past such as cancer, diabetes, heart disease, etc.

Please share a little about any traumatic experiences you might have had.

What is your current intention for your ceremony? Not to worry, this can and often will evolve before the actual ceremony.

What other information would you like me to know?

Please list any dietary restrictions.

For group events, please provide your phone number so I can add you to the What's App Group.

Emergency Contact - please list one person and their phone number that we could reach if needed.

Initials

I declare that the information I’ve provided is accurate and complete. I understand that providing incorrect information can result in harm.