Indigenous Medicine

Ceremony Intake

This is the screening that lets us hold you safely.

It is longer than most forms, and it is meant to be. Your answers stay between you and the guides who hold the circle. Please complete it with honesty and presence; there is no answer here that disqualifies you from being cared for.

Who you are

Name

Phone

Date of birth

Address line 1

Address line 2

City

State

ZIP code

Emergency contact: name, relationship, and number

Your intention

What are you hoping to release?

If this experience were truly transformational for you, what would shift in your life?

Health and safety

Required for screening. Answer plainly. Nothing here is judged, and it is what keeps the circle safe for you and for everyone in it.

Have you worked with Kambo, Bufo, Ayahuasca, Hapé, or Yopo before?

Yes No

If yes, tell us about it

Are you currently fasting or detoxing?

Yes No

Which gathering is this intake for?

Preferred date, if it is a private session

Please list any current medications, supplements, or substances you are taking

Any recreational substance in the past 7 days?

Yes No

Any recent illness, fever, infection, vomiting, or diarrhea in the past 7 days?

Yes No

Do you have any fears, questions, or concerns about the experience?

Do you currently have a support system? Friends, therapist, community?

A guide reads every intake personally. If anything in your answers needs a conversation, we will call before the ceremony rather than after.

Received, with gratitude