Intake, Waiver and Release Form for Men's Ceremony - January 24, 2026
For safety and efficacy reasons, and as a crucial part of our screening and assessment, please review and fill out the intake form. After we review the information, we will contact you to schedule a call to discuss next steps.  

This medical screen intake and waiver must be completed prior to the start of each ceremony. Even if you have participated in a ceremony with us before, a new intake form must be completed prior to each ceremony.

This form is comprehensive and follows a specific trauma informed approach. 
All information is confidential and private. In some rare cases, we may need to consult a medical specialist or medical holistic practitioner for more clarification on specific conditions or contraindications, but only with your consent.  

Blessings, Energy Body Wellness Team

Sign in to Google to save your progress. Learn more
Email *
Personal Information :
1. What is your first name? What name do you prefer to be called by?
 *
2. Last Name
 *
3. What is date of birth
 *
MM
/
DD
/
YYYY
 4. What is your email address
 *
5. What is your phone number?
Please include your country's area code
example: (+1 Canada/US) (+506 Costa Rica) (+44 England)
 *
Is your phone number linked to a WhatsApp Account?
 *
Required
Emergency Contact Information

1. Who should we contact in case of an emergency? Include full name
 *
2. Emergency contact phone number (including International country code)
 *
3. What is their relationship to you.
 *
Relevant History of Plant Medicine

1. How did you hear about this ceremony? 
 *
2. Do you have experience with plant medicine or psychedelics in a ceremony context? *
Required

If yes, which ones? (e.g cannabis, mushrooms, MDMA, ayahuasca, 5-MEO-DMT, ketamine, Huachuma, peyote, etc.)
 *
3. How often have you used plant medicines in a ceremonial intentional setting?
 *
4. Have you used plant medicines or other substances recreationally before? If so, which ones? (e.g cannabis, cocaine, mushrooms, MDMA, ketamine, DMT, heroine, opiods, GHB etc)
 *
5. List any psychedelic substances used socially or in ceremony in the last 60 days (choose all below)? *
If other, what other substances have you used in the last 60 days.
Physical Health Conditions, Including Family History

1. Do you have any chronic physical health conditions? If so, please specify.
 *
2. Are there any physical health conditions that run in your family?
 *
3. Have you had any recent surgeries or hospitalizations? If so, what and when?
*

Current State of Health and Wellbeing:

1. How would you rate your overall physical health? (Excellent, Good, Fair, Poor)

 *

2. Are you experiencing any pain or discomfort at the moment? If 'yes' please describe.

 *
3. Do you have a heart condition or a history of heart problems (choose all below)? *
If yes to prior question provide details.
4. Do you currently have or have had in the past chronic health conditions (choose all below)? *
5. If yes to prior question provide details.
Are you pregnant? *
Medication and Natural Medication Use:

1.What prescription medications are you taking? Include any prescription medications taken in the last 3 months (list all here as well as amount and how often you take(took) them) *
2. What over the counter medications are you taking? Include over the counter medications taken in the last 3 months (list all here as well as amount and how often you take them) *
3 Have you recently stopped taking any medications? If so, please specify.
 *
4.What herbs and supplements are you taking? (list all here as well as amount and how often you take them) *

Relevant History of Psychological Health Conditions, Including Family History:

1. Have you experienced any significant psychological or emotional difficulties in the past?

 *
Required
2. Do you have any diagnosed psychological health conditions? If so, please specify all that apply? *
Required
If yes to prior question, please provide details.
3. Have you ever received therapy or counseling? If so, for what reasons and for how long?
 *
 4. Have you ever experienced trauma or PTSD?
 *
5. Are you currently experiencing any psychological or emotional distress?
 *
6. What do you do to cope with stress and emotional challenges?
 *
7. Have you ever been hospitalized for psychological reasons?
 *
8. Are there any psychological health conditions that run in your family?
 *
9. Do you have any significant life events or experiences that you believe are relevant to share?
 *

History of Addiction and Substance Abuse:

1. Have you ever had issues with addiction or substance abuse? If so, please provide details.

 *
2. Are you currently using any substances, including alcohol or drugs?
 *
3. Have you received treatment for addiction or substance abuse in the past?
 *
Dietary Requirements and Allergies

1. Do you have any food restrictions?
2. Do you have any food allergies? *
If yes to above, please list.
Intention for Attending this Plant Medicine Session

1. What is your main intention for attending this Plant medicine ceremony? 

 *
2. What do you hope to achieve or learn from this experience?
 *

Integration Process and Requirements

1. How do you plan to integrate the experience from the Plant Medicine session into your daily life?

 *
2. Do you have access to support systems for post-session integration?
 *

Current State of Environment and Support

1. Describe your current living environment. Is it stable and supportive?

 *
2. Do you have a strong support network (family, friends, community)?
 *

3. Are there any stressors in your current environment that may affect your well-being?
 *
Are you a Costa Rica resident (live in Costa Rica 10 out of 12 months a year), citizen, or visitor *
If you do not live in Costa Rica, how many days will you be staying in Costa Rica after the ceremony?  (We strongly suggest allowing at least 1 full day of integration post ceremony before taking a long trip or flight)
 *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms