SANCTUARY 72 PRIVATE CEREMONY INTAKE FORM
We appreciate you taking the time to fill out this intake form.  The questions we have here will offer us a deeper insight into how best to serve you in medicine and which one of our facilitators will be the most suitable for your experience.

Please take your time filling this out.  Once complete someone from our team will reach out via text or email to schedule a video chat.

We look forward to serving you and helping you expand your consciousness.

Mahalo!
Sanctuary 72
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Email *
Name *
Phone Number *
Current Location: City & State *
How did you hear about us? *
Is this your first time using psychedelics?
Do you have any health concerns we should be aware of?
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Do you have any food allergies and or dietary restrictions? *
What plant, animal or pharmaceutical medicines do you or have you worked with?
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What’s the highest dose of mushrooms you’ve taken in one sitting?
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Are you currently using, or have you used within the past month, any mood altering pharmaceuticals such as SSRIs or  antidepressants?
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Do you have a history of any significant traumas that are currently dealing with? If so, can you please share in more detail.
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Do you have history of sexual abuse?
How do you want to feel about yourself and your life after this ceremony?
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Are you currently under the care of a therapist?
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What is the main reason you are seeking psychedelic therapy and ceremony?
What do you want to receive through participating in this ceremony?
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Are you pregnant or nursing? *
Have you ever been in the military? and if so what service and for how long?
How do you typically handle stress?
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HAVE YOU BEEN DIAGNOSED BY A PSYCHOLOGIST OR PSYCHIATRIST FOR HAVING: CLINICAL DEPRESSION, ANXIETY, PTSD, BIPOLAR, BORDERLINE PERSONALITY, OR OTHER PSYCHIATRIC CONDITIONS?

- PLEASE LIST CONDITION AND PROVIDE CONTACT INFO OF THERAPIST - NAME & PHONE #

Have you ever experienced psychotic episodes? 
Have you ever had an addiction to substances or other?

Do you have a meditation, yoga or mindfulness practice? If so, please elaborate.

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How often are you present with silence?
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How do you feel about your life presently?
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Who are your mentors?
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What is your relationship with money? *
What is your relationship with self love?
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What dream do you want to create as a reality?

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Please provide emergency contact info
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