Spirit of Earth Entheogenic Church              APPLICATION & SCREENING FORM FOR PLANT MEDICINE PARTICIPATION
All prospective participants must complete this client history form prior to joining in a plant medicine ceremony. The purpose of this assessment is to keep you and this sacred work safe. The information collected will help us and your facilitators to understand potential contraindications and side effects in order to prevent any unforeseen issues before they occur. Please be honest with your answers. What is prescribed for you and how you feel are extremely important. Be kind to yourself!

AS A PARTICIPANT:

I UNDERSTAND THAT THE INFORMATION PROVIDED HEREIN WILL ONLY BE USED TO DETERMINE IF IT IS APPROPRIATE FOR ME TO PARTICIPATE IN A SPIRIT OF EARTH PLANT MEDICINE CEREMONY AND WHOM TO CONTACT IN AN EMERGENCY. THIS INFORMATION WILL REMAIN CONFIDENTIAL AND IT WILL BE USED TO ASSESS SAFETY AND THE SUBSTANCES THAT WILL WORK BEST FOR ME.

 

I MUST KEEP MY FACILITATORS INFORMED OF ANY CHANGES TO MY MEDICAL HISTORY BEFORE I ATTEND A CEREMONY. WHEN IN DOUBT OF WHAT TO REPORT, I WILL CONTACT A SPIRIT OF EARTH FACILITATOR.

Sign in to Google to save your progress. Learn more
Email *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Shamanfire.

Does this form look suspicious? Report

Google Forms