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Thank you for taking part in a Taste of Magic  
I acknowledge the courage it takes to say ‘Yes’ to something new like this.  You are fully supported and I am here to walk with you through this process before, during and after your journey.  In order to ensure that you feel fully prepared for the journey, please complete this intake form below as soon as possible.  If you have questions, please schedule a call this week with me here.  

We are here to take care of you.  The preparation and integration is for you and we'd love to connect before and after as you need.  
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First Name Only  *
Contact Number *
Emergency contact, please provide first name, contact info and relationship: *
Have you experienced medicine work in the past? *
I understand that to support myself having the best experience possible I should not drink alcohol or take any substances 72 hours prior to the event and will eat as cleanly as possible (no processed foods, seed oils or added sugar).  *
I understand that I should not eat any food after 10am on the event day and I am to drink plenty of fluids including electrolytes the day prior and day of.   *
I understand that I must share my history of taking antidepressant medication (SSRIs, MAO inhibitors) or anti-hypertensives (high blood pressure medication).   This is safety precaution. *
Please list prescription medications (brand name + dosages, may answer none if does not apply) *
Please share if you have any history with PTSD, addiction, anxiety, depression, etc. *
Please list any medical issues or concerns you have as well as family history of mental illness.
What inspired you to want to partake in this experience?
Please share your intentions for this experience in as few words as possible - one word is enough too!
What aspects of your life do you want to work on? What would you like to improve? *
I understand that I am not to drive after the meditation and will arrange transportation to drop me off and pick me up from the location of the meditation.    *
Anything else you'd like to share? 
I am voluntarily taking part in Taste of Magic Sound Meditation in Santa Barbara.  I am in reasonable health and am not otherwise limited by either minor or serious mental or physical injury, disability or illness that could potentially render me particularly susceptible to injury or disability while participating in this workshop.  MY PARTICIPATION IN THIS EVENT IS AT MY OWN SOLE RISK. I agree to hold Power of Your Om, LLC on behalf of myself and/or any person or entity acting through or on behalf of me, harmless and forever and unconditionally release Power of Your Om, LLC, and any affiliated entities, parent companies, subsidiaries, present and former employees, owners, officers, members, managers, partners, contractors, insurers, shareholders and directors of the foregoing. (Collectively, “Released Parties”), from any and all claims, actions, damages, liabilities, losses, costs and expenses in any way arising out of, or resulting from, my participation in the event, including, without limitation, any and all claims, actions, and liabilities for death, injury, loss or damage to me or to any one else, or to any property, regardless of whether or not such injury, loss or damage was caused by the negligence or willful conduct of Power of Your Om, LLC, Adrienne Smith, or any of the Released Parties.

I understand the legal consequences of doing so which includes a release of Power of Your Om, LLC, Adrienne Smith, from all liability related to the event and promising not to sue the Company and assuming all risks involved in the workshop known or unknown. I am willingly participating with the above clear understanding.
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