Private Plant Medicine Ceremony 
Congratulations in taking this step toward your healing journey! & Thank for your trust in guiding you through  this moment. Please fill out your information below so we can tailor a program best made for you. We will be in touch for further information & scheduling within a few days. 
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Name (First/Last) *
Age *
Contact Info (Phone/Email) *
How many people will be joining you? *
How long would you like your ceremony to be? *
Any health concerns? *
Are you currently pregnant? *
History of low blood pressure? *
Are you on anti-depressants or anxiety medication? *
Allergies? Please note them below *
Have you already participated in any kind of ceremony? *
Do you have experience with plant medicines? Are you already familiar with any? If yes, list them in "other". *
What plant medicine do you want to call in for this ceremony? (Select All That Apply) *
Required
Do you uphold any spiritual beliefs or practices? Explain Briefly *
In this present moment, do you feel called to release and let go of old cycles/patterns OR are you being called to manifest new beginnings & opportunities? *
What are you looking to work through or call in at this time? Do you have a specific intention in mind? *
(If you have any) What are your biggest concerns regarding this ceremony? *
Please give us your availability or preferred date/time over the next two to three weeks. *
If you would you like for us to come to you for this ceremony, please note your address below. *
Any questions? *
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