Hummingbird Heart Sacred Medicine Church Membership Application and Assessment Form
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Email *
First Name *
Last Name *
Address *
Please include your street address
City, State, and Zip Code *
Please put your City, state, and the zip code.
Phone Number *
Do you receive texts on the phone number listed? *
Date of Birth (XX/XX/XXXX)
 *
Male or Female *
Marital Status *
Occupation
EMERGENCY CONTACT *
Please enter your Emergency contact's: Name, Relationship to you, and their phone number.
Medical and Dietary
Please note there are certain medications and medical conditions that are not safe to combine with Ayahuasca. However there are other Sacred Medicines (Such as Mushrooms, Peyote, San Pedro, etc.) that can be safely combined so that you may still be able to participate in Ceremony.
1. Do you have any pre-existing medical conditions? *
 (Heart conditions, diabetes, high blood pressure, etc)?
If yes, please describe.
2. Do you have any psychological conditions? *
If yes, please describe.
3. Are you currently taking ANY medications, vitamins, and or supplements? *
Such as: Any medications or herbals that contain MAO inhibitors, any medication that has an effect on the serotonin system, including Selective Serotonin Reuptake Inhibitors (SSRIs) (antidepressants such as Wellbutrin, Prozac, Zoloft, Effexor, etc.) Including non-prescription over the counter medications such as: Decongestants, cold medications, allergy medications, Ibuprofen, antihistamines, sedatives, tranquilizers, amphetamines (including Adderall), hypertensive medications, sympathomimetic amines including pseudoephedrine, tyrosine, tryptophan, asarone/calamus, asthma, inhalers, birth control, and diet pills. Also, Herbal Antidepressants and Pain Relievers such as: St. John's Wort, Kava, Kratom, Ephedra, Ginseng, Yohimbe, Sinicuichi, Rhodiola Rosea, Kanna Boswellia, Nutmeg, Scotch Broom, Licorice Root, Cannabis, etc.
If yes, please list the name, amount, how often, what for.
4. Have you discontinued taking any medications or supplements that may be contraindicated with Ayahuasca? *
Such as: Any medications or herbals that contain MAO inhibitors, any medication that has an effect on the serotonin system, including Selective Serotonin Reuptake Inhibitors (SSRIs) (antidepressants such as Wellbutrin, Prozac, Zoloft, Effexor, etc.) Including non-prescription over the counter medications such as: Decongestants, cold medications, allergy medications, Ibuprofen, antihistamines, sedatives, tranquilizers, amphetamines (including Adderall), hypertensive medications, sympathomimetic amines including pseudoephedrine, tyrosine, tryptophan, asarone/calamus, asthma, inhalers, birth control, and diet pills. Also, Herbal Antidepressants and Pain Relievers such as: St. John's Wort, Kava, Kratom, Ephedra, Ginseng, Yohimbe, Sinicuichi, Rhodiola Rosea, Kanna Boswellia, Nutmeg, Scotch Broom, Licorice Root, Cannabis, etc.
If so, please list the name, what for, and how long it has been since you discontinued it.
5. Do you have any dietary requirements? *
For example, vegetarian or lactose intolerant.
If yes, what dietary requirements do you have?
6. Do you have disabilities? *
If yes, please explain any accommodation needs that you may have.
7. Are you allergic or have any sensitivities to anything? *
Please note tobacco, cedar, sage, and other incense smoke is used in our ceremonies. We also have one small dog and two cats.
If yes, what are you allergic or have sensitivities to?
8. Do you drink alcohol? *
If yes, please explain how much, how often, and what for?
9. Do you have a history of any drug use? *
If yes, please state your history of all drug use.
Such as: Cocaine, Heroin, LSD, MDMA, etc.
10. Do you have anything else in your history that we should be aware of? *
If yes, please explain.
Emotional Well Being
11. Do you have a history of any kind of abuse/trauma? *
Please check all that apply.
Required
Explain if you are comfortable doing so
12. Do you have a history of harming yourself in any way? *
Please check all that apply.
Required
Explain if you are comfortable doing so
13. Are you currently in an abusive or dangerous situation? *
What type? Check all that apply.
Required
Explain if you are comfortable doing so
14. Are you currently suffering from any unresolved emotional issues? *
(Childhood traumas, loss of a loved one, unhealthy relationships, feelings stuck in a situation, etc.)
 If yes, please state the issues and only explain if you are comfortable doing so.
Plant Medicines & Ceremonial Practices
15. Do you have any experience with the ritual use of any plant medicines such as Ayahuasca, Peyote, San Pedro, Mushrooms, etc?
If yes, how many times have you sat in ceremony with each medicine? If you cannot remember the exact amount, give an estimate.
16. Have you used any of the plant medicines outside of Ceremony or not ritually?
If yes, how many times have you had medicines non-ritually, and which ones?
Religious/Spiritual Background
17. Please describe your religions background and/or spiritual belief system.
18. Do you have experience with other spiritual practices and or healing modalities?
(Yoga, meditation, reiki, etc) If yes, please explain.
Hummingbird Heart Sacred Medicine Church offers ceremony only for those who are truly in need of help and are seeking their own personal healing and/or are looking for their tribe to vibe with as they continue their personal work with sacred plant medicine(s).
19. What is your reason for wanting to come to ceremony?
20. What are you seeking help with?
21. Is there a specific sacrament that you are being called to?
22. Why have you chosen our church?
23. What questions do you have for us?
24. Have you received a Covid Vaccine? If so how many and how long has it been since your last injection?
25. You must complete this questionnaire AND have a phone consultation with us before you will be able to sign up & reserve your space for Ceremony. When is the best time to reach you?
Please provide time zone.
What ceremony weekend are you interested in reserving?

October 3rd & 4th

November 7th & 8th


Other Dates TBA
I understand withholding critical medical information can be dangerous and is likely to put my life at risk. I swear to the best of my knowledge I have been truthful and have not withheld any critical information. *
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