Immortal Freedom- Health History Form
Please fill out completely and accurately. Information provided will inform the discussion during our discovery call. All information provided will be kept in strict confidence.
Email *
Name *
Email *
Date of Birth *
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Address
Phone number *
Emergency Contact Information: Name, relationship, phone number *
How did you hear about Immortal Freedom/Sapo Society? *
Have you ever attended a sacred medicine ceremony before? If yes, when and what medicine/s? *
What event or appointment are you interested in scheduling? Please include name of event and specific date and time. *
Which ceremonies are you interested in? *
Required
Are you currently taking ANY prescription medications, such as MAO inhibitors, SSRI's, NDRI's etc..? *
If yes, please list ALL medications, dosage, duration of use and prescribed reason for use. (if none, please type "none") *
Are you currently taking any herbal medicines or nutritional supplements? *
If yes, please list all including dosage, duration and reason for use. (if none, please type "none") *
Have you ever been in the Military? *
Do you have any allergies to medication, food, or any dietary restrictions? *
Have you been vaccinated against COVID-19? *
Our facilitator uses Mapacho (a species of tobacco found in the amazon used for sacred ceremonies) will this be a problem for you?
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Do you have a spiritual practice or belief? If so, please share. If no practice is in place or you do not wish to share, please type "none". *
Are you currently in therapy or seeing an integration therapist?
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Have you ever been hospitalized for a psychological or emotional problem? If yes, please describe. Be sure to include dates, reason and diagnosis. *
Are you or have you ever experienced anxiety and/or depression? If yes, please describe. *
Do you have or have you ever had a substance abuse problem? If yes, please describe. Be sure to include substance, amount and any recovery treatment. *
Have you ever caused physical harm to yourself or others? If so, please explain circumstances. *
Are you trained in marshal arts or any other version of self defense training? *
Do you consume alcohol? If yes, how much and how often? *
Do you use psychoactive/psychedelic substances? If yes, which ones and how often? *
Are you currently pregnant? *
Have you ever experienced or been diagnosed with any of the following? *
Required
For health and safety reasons you cannot attend a ceremony if you have taken SSRI's or NDRI's within 2 weeks and any other substances within 3 days prior to ceremony. *
Is there anything else you would like to share about yourself or want us to know?
Please Print your full name below to affirm the following: All of the information on this application is true and accurate. I understand that if I attend a ceremony I will be required to sign a Waiver of Liability and that I am participating at my own risk.

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