The Love Evolution Journey Questionnaire
Please join me on November 23, 2019 in West Palm Beach, Florida to participate in The Love Evolution Sacred Medicine Journey.

Our journey will be hosted at a private location and documented for our film The Sacred Journey Within.

After you have secured your space on the www.farrahsharpe.com website, please fill out this application and I will contact you soon. - Farrah

Email address *
Full Name: *
Your answer
Address: *
Your answer
Phone Number: *
Your answer
Email: *
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Occupation: *
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Facebook , Instagram and other social media profile links * *
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Gender: *
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Date of Birth: *
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Emergency Contact Name: *
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Emergency Contact Phone: *
Your answer
Are you coming alone or with a companion? If with a companion, please share their names with me here and send them this form. *
Your answer
Diet: *
Food allergies and restrictions? *
Your answer
Are you taking any supplements? If so, what kind? Name of supplement and brand. *
Your answer
Do you have any medical conditions? *
Your answer
Are you taking anything prescribed to you by a Doctor for health reasons? If so, please list what medications and their uses. *
Your answer
Do you have any medical or psychological conditions? * Have you ever been hospitalized? Explain:* *
Your answer
Why do you want to come to the ceremony? *
Your answer
Do you have any previous experience with shamanic plants, sacred journeying with shamans, or other retreats? If so, how many times, when and where? *
Your answer
Have you taken any sacred medicines or psychedelics before? Cannabis, Psilocybin or “Magic Mushrooms , Ayahuasca, Changa, Rape', San Pedro: Huachuma, Peyote; Mescaline, MDMA, LSD, Ketamine, Iboga, or others? If so please list all that you have taken, where, and when. *
Your answer
Have you in the past or are you currently taking any drugs? I.E. Cocaine, Crack, Heroin, Pharmaceuticals, or anything else? If so, please list what and when. *
Your answer
Do you meditate? Yes *
Do you practice yoga? *
Do you have a self-care practice or do you need to learn? If so, what does your practice look like? *
Your answer
What do you do when you feel stressed? *
Your answer
Do you experience PTSD? *
How do you handle crises? Explain: * *
Your answer
Do you have a history with any type of substances or addictions? Explain: *
Your answer
Were you treated by a psychologist, psychiatrist, or mental health professional in the past. If so, what happened? When and where? *
Your answer
What 3 things do you love most about life right now? *
Your answer
What are you grateful for? *
Your answer
What caused you the most pain in your life? *
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What's your happiest memory? *
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What's your favorite song? *
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What's your favorite fruit? *
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What do you think about the Earth and the current state of our world? *
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If you could change three things about your life, what would you change? *
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Would you like to participate in the Documentary Film The Sacred Journey Within and be filmed at the ceremony?
Are you able to commit to a Pre-Care and After-Care Mind-Body Medicine self-care and self-love practice to prepare you for the journey and to integrate your process after this journey? 1 Pre-Care Session and 1 After-Care Session is included. You will be responsible for setting up both appointments with me. This is to help you develop a long term personal growth practice to support your spiritual growth. Since shadow issues, childhood trauma, and other forms of pain arise for healing with this work, this is a requirement for all who journey with me. *
Are you a therapist, body worker, or healer? Or have you worked with one in the past? Explain: *
Your answer
How did you hear about me? *
Your answer
Do you have a passport? (For future Journey's)
Which future Journeys are you interested in? *
Do you have health insurance? *
Name of your current medical provider.
Your answer
We will be wearing All White with Purple/Indigo accessories. Do you agree to come dressed in ceremony wear. *
Any other questions or comments?
Your answer
Thank you. Namaste.
I will be in touch with you soon. - Farrah
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