Kambo Questionnaire
Allow me to get to know you. This is an in-depth questionnaire that will allow me to know if you are a proper candidate to work with Kambo. There are also some very personal questions. These questions will let me know why you are wanting to work with Kambo and to give me some in site on what you are experiencing. Everything you share is 100% confidential. Thank you for being open and honest.

Before filling this form out, be sure you have read over all the details of Kambo Ceremonies and you are fully ready to start your journey with Kambo. you can find all information here KAMBO INFORMATION
Email *
Full Name *
Email *
Date of Birth *
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Phone number *
Gender
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What is your address? *
Emergency Contact *
Name and phone number
How did you hear about PachaSoul? *
Who might we thank for referring you to us? *
When did you hear a calling to work with Kambo? *
How was this call heard? *
Do you have any personal experience with using Kambo? *
If you have experienced Kambo before, how many ceremonies and when. What have you healed with Kambo? Please explain below:
Have you independently researched Kambo, it’s history, and how it interacts with the body/energy system? *
Do you have any personal experience working with any other plant/animal medicines? *
If yes, what other medicines have you worked with and how was that experience?
Are you pregnant or think that might be pregnant? *
Breastfeeding a child under 1 year? *
Do you have any of these serious heart conditions: *
Required
Do you suffer from high or low blood pressure? *
Have you had a stroke, aneurysm or bleeding in the brain? *
Have you ever had organ transplant surgery? *
If Yes, please detail the surgery and which organs.
Any condition already treated by GP or another complementary or alternative practitioner: *
Required
Please elaborate on any of the above checked conditions or treatments. *
Kambo has no known detrimental side effects, so when it is responsibly administered, it is completely safe. There are some people for whom it should not be administered. Indicate if you have any of the following contraindications: *
Required
Have you been hospitalized in the last 20 years? *
If yes, please explain
Are you currently or have you ever received Therapy, attended a support Group, and/or worked with a Counselor, Psychiatrist, Psychologist or Psychotherapist? *
If yes, please explain
Is there anyone in your family with a history of psychiatric disorders? *
If yes, please explain
Have you experienced traumas in your life? This includes traumatic events as well as ongoing traumatic experiences. *
If yes, please explain
If YES, has this influenced your desire to work with Kambo? *
Do you drink alcohol? *
If YES, are you willing to fully detox off of any alcoholic substances a minimum of 7 days prior to Your Kambo Ceremonies?? *
Do you use any "illegal" substances including Cannabis? *
If YES, are you willing to fully detox off of any substances a minimum of 7 days prior to your Kambo Ceremonies? *
Are you taking ANY western medical prescriptions, over-the-counter, or alternative, homeopathic medications or taking herbal supplements? *
If yes, please explain.
Why do you have an interest in working with Kambo? *
Is there anything else we should know about your physical or mental state? *
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