Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever been hospitalized? *

Yes

No

Are you currently on any prescribed medication? *

Yes

No

Have you taken any prescribed medication in the last 6 months? *

Yes

No

Do you have any environmental allergies or sensitivities? *

Yes

No

Have you experienced a recent crisis or big life change? *

Yes

No

Have you ever been diagnosed with a psychiatric condition?

Yes

No

Do you currently, or have you ever, taken medication for depression, anxiety, or any other psychological condition? *

Yes

No

Have you ever been hospitalized for a psychiatric condition? *

Yes

No

Have you ever made any suicide attempts or had suicidal ideations? *

Yes

No

Do you have any self-destructive or violent behaviors? *

Yes

No

Is there any known history of mental illness in your family? *

Yes

No

Do you currently, or have you ever, experienced PTSD? *

Yes

No

What is your experience with altered states, if any: *

Yes (recently)

Yes (in the past)

None

Were you raised in a religious or spiritual tradition? *

Yes

No

Have you ever worked with any shamanic traditions or lineages? *

Yes

No

Do you currently have a spiritual or meditation practice? *

Yes

No

Have you done other kinds of healing work? *

Yes

No

*

I have read and agree to the Consent & Waiver Form above

Date

MM

DD

YYYY