Alchemy of The Spirit Goddess Retreat Egypt | The Sacred Journey Within Questionnaire
Thank you for signing up to participate in Alchemy of the Spirit Goddess Retreat and the Filming of
The Sacred Journey Within Documentary Film.

After you have secured your space (CashApp $farrahsharpe) Please fill out this application and I will contact you to scheduling your pre-care appointments. - Farrah
Email address *
Full Name: *
Address: *
Phone Number: *
What's the best time to reach you? *
Facebook , Instagram and other social media profile links * *
Gender: *
Date of Birth: *
MM
/
DD
/
YYYY
Emergency Contact Name: *
Emergency Contact Phone: *
Are you coming alone or with a companion? If with a companion, please share their names with me here and send them this form. *
Diet: *
Food allergies and restrictions? *
Are you taking any supplements? If so, what kind? Name of supplement and brand. *
Do you have any medical conditions? *
Are you taking anything prescribed to you by a Doctor for health reasons? If so, please list what medications and their uses. *
Do you have any medical or psychological conditions? * Have you ever been hospitalized? Explain:* *
Why do you want to come to the ceremony? *
Do you have any previous experience with shamanic plants, sacred journeying with shamans, or other retreats? If so, how many times, when and where? *
Do you smoke, eat, or ingest Cannabis? *
Are you currently experiencing any chronic pain? *
Are you currently experiencing anxiety, panic attacks or have any phobias? If yes, when did you begin experiencing this? *
Are you currently experiencing overwhelming sadness, grief or depression? *
How would you rate your current sleeping habits? 1 No Sleep - 5 A Great Nights Rest *
How many times per week do you generally exercise? *
Have you taken any sacred medicines or psychedelics before? Cannabis, Psilocybin or “Magic Mushrooms , Ayahuasca, Changa, Rape', San Pedro: Huachuma, Peyote; Mescaline, MDMA, LSD, Ketamine, Iboga, or others? If so please list all that you have taken, where, and when. *
Have you in the past or are you currently taking any drugs? I.E. Cocaine, Crack, Heroin, Pharmaceuticals, or anything else? If so, please list what and when. *
Clear selection
Do you meditate? Yes *
Do you practice yoga? *
If yes, what style of yoga? *
Do you have a self-care practice or do you need to learn? If so, what does your practice look like? *
What do you do when you feel stressed? *
Do you experience PTSD? *
How do you handle crises? Explain: * *
Do you have a history with any type of substances or addictions? Explain: *
Were you treated by a psychologist, psychiatrist, or mental health professional in the past. If so, what happened? When and where? *
What 3 things do you love most about life right now? *
What are you grateful for? *
What caused you the most pain in your life? *
What's your happiest memory? *
What's your favorite song? *
What do you consider to be some of your strengths? *
What do you consider to be some of your weaknesses? *
What is your biggest block in life? *
What do you fear? *
What's your worst habit? *
What is your Astrological Sun Sign? *
Do you practice religion? If so, which one? *
Are you currently employed? If yes, what do you do? Do you enjoy your work? *
What's your favorite fruit? *
What do you think about the Earth and the current state of our world? *
If you could change three things about your life, what would you change? *
Would you like to participate in the Documentary Film The Sacred Journey Within and be filmed at the ceremony? *
Are you able to commit to a Pre-Care and After-Care Mind-Body Medicine self-care and self-love practice to prepare you for the journey and to integrate your process after this journey? 1 Pre-Care Session and 1 After-Care Session is included. You will be responsible for setting up both appointments with me. This is to help you develop a long term personal growth practice to support your spiritual growth. Since shadow issues, childhood trauma, and other forms of pain arise for healing with this work, this is a requirement for all who journey with me. *
Are you a therapist, body worker, or healer? Or have you worked with one in the past? Explain: *
How did you hear about me? * *
Do you have a passport? *
You will need a Visa for Egypt. Do you agree to get your visa? *
Do you have health insurance? *
Name of your current medical provider. *
Family Mental Health HistoryIn the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.) Please List Family Member and the situation. If you have experienced these Indicate this below by saying I have experienced this and list the situation. 1. Alcohol/Substance Abuse. 2. Anxiety Depression 3. Domestic Violence 4. Eating Disorders 5. Obesity 6. Obsessive-Compulsive Behavior 7. Schizophrenia 8. Suicide Attempts *
Confidentiality Agreement. I am bound by professional ethics to protect client rights to confidential communication. All issues discussed in the course of counseling are strictly confidential (including children age 14 years and older). By law, health care information pertaining to you may be released only with your written consent or the consent of a parent or legal guardian. For this reason, if you want your therapist to release information about your participation in therapy, you will be asked to sign a “Release of Information,” valid for ninety (90) days from the date of signature. The law (RCW 18.19.180) does provide exceptions to client confidentiality where information may be released without your consent:1. In the event of a medical emergency, information deemed necessary for treatment may be released. 2. In the event of a threat of harm to oneself or someone else, if that threat is perceived to be serious, the proper individuals must be contacted. This may include the individual against whom a threat is made.3. In the event of suspected abuse of a child, dependent adult or elder, the proper authorities must be contacted. The abuse does not have to be personally witnessed by the counselor.4. If you register a complaint with the Oregon State Department of Health, the information will be released as requested or required by the State to resolve the issue.5. If ordered by a judge or other judicial officers, information regarding your treatment must be disclosed.6. In the event of a client’s death or disability, the information will be released as authorized by the client's personal representative or beneficiary.7. A counselor is not required to treat as confidential communication that reveals the contemplation or commission of a crime or harmful act. 8. Evidence that a minor client was a victim of a crime may be released to the proper authorities. Please click yes if you have read this confidentiality agreement. *
Consent for Treatment I have read, initialed, and understand the above policies and procedures and informed consent information of Farrah Sharpe, MS, RYT. I understand that I may terminate treatment at any time and that if I have any complaint or grievance regarding my treatment, I will be provided assistance. I agree to the stated terms of treatment and hereby give my consent for treatment. I also acknowledge that I will receive a copy of this agreement. By Typing your name this is equivalent to a signature and will be used as your lawful and binding electronic signature. *
The Content shared in our sessions is not intended to be a substitute for professional medical advice, diagnosis, or treatment. I am a Mind-Body Medicine Specialist, and I work with your Doctor. Please share our sessions with your primary care physician, Therapist, or Psychiatrist. If you are having an emergency please call 911 immediately. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on my website or we have discussed in the session. If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately. I do not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on FarrahSharpe.com. Please select yes if you understand. *
Video Release Form1. I grant the Producer (Farrah Sharpe and her video team, and its designees the right to use my photos and video footage taken at the Sacred Journey Within Production any format, now known or later developed. I grant, without limitation, the right to edit, mix or duplicate and use or re-use in whole or in parts as Producer may elect. Producer or its designees have complete ownership of the Product, including copyright interests. 2. I grant Producer and its designees the right to broadcast, exhibit, market and otherwise distribute the Product, in whole or in parts, and alone or with other products, for any purpose Producer or its designees determine. This grant includes the right to use the media for documentary film, youtube, Facebook, Instagram, twitter, linked and other mediums, online and print formats for promoting or publicizing. 3. I have the right to enter into Agreement and am not restricted by commitments to third parties.4. The producer has no financial commitment or obligations to me as a result of the Agreement. 5. In consideration of all the above, I hereby acknowledge receipt of reasonable and fair consideration from Producer. I have read, understand and agree to all of the above and that the rights granted Producer herein are perpetual and worldwide I agree to the terms above. Please type your name below. This serves as a digital signature. *
We will be wearing All White with Purple/Indigo accessories to Ceremony. Do you agree to come dressed in ceremony wear? *
Which future Journeys are you interested in? *
Please answer yes or no to the following statement: I hereby give Farrah Sharpe & The Sacred Journey Within permission to use my photographic likeness in images or videos taken during this retreat on their website, in print material or other broadcast media for the use in promotion of their projects and programs.
Clear selection
Any other questions or comments?
Thank you. Namaste.
I will be in touch with you soon. - Farrah
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