Ecstasis - Application & Health Screening Formula
Your safety and comfort are our top priority. Because there are certain contraindications for this type of work, it is very important that you fill out the following form as completely, honestly and openly as possible. If I detect any contraindications, I will reach out directly to you to follow up. If you have any questions, please feel free to contact me.
Email *
Name *
Mobile Numer *
Emergency Contact Nr./Relationship *
Your Profession
Birthdate *
MM
/
DD
/
YYYY
What are your top challenges in life right now? *
Briefly explain why you feel called to this experience. What are your intentions for participating? What do you hope to achieve? *
Do you have any regular personal development, spiritual or physical practices you do? If so, please briefly explain. *
Have you ever attended another retreat - yoga, meditation, personal development, wellness, training, plant medicine etc.? *
Do you have experience with any of the following? (all answers are confidential) *
Required
If yes, which have you used in a "ceremonial" setting (as opposed to recreationally) *
Required
Briefly describe your experiences with psychedelics, how they affected you, sensitivity, tolerability, good/bad experiences, etc. (if applicable) *
Are you currently taking any pharmaceutical and/or herbal medications? If yes, please list name and dosage (if none, write "none") *
Have you or your family members ever been diagnosed with any of the following? *
Required
If yes, please indicate who was diagnosed, when and whether this was by a doctor or self-diagnosis.
Do you have any physical impairments we should be aware of? This includes recent heart attacks, stroke, blood pressure, major surgeries, disabilities, etc. *
If yes, please list
Any medical and/or other personal information you would like to make us aware of?
Any dietary restrictions?
*Please note, neither I nor any of the assistants are doctors or medical professionals, and our review of your health screening in no way indicates medical advice or approval. Please check with your doctor if you have concerns.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy