LIFE COURSE QUESTIONS
Life course / pain points / trauma (eg. parental divorce, bullying, accident etc.) We need this information to determine how best to support you during the ceremony. This intake conversation will remain confidential and will be destroyed after the ceremony. lf you have any questions or comments during the completion of the intake form, you can always contact us. lf you cannot answer certain questions, that's not a problem. lf you have any questions arising from your answers we will contact you in due time. 

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Email *
Retreat start date:
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Full Name: *
Date of Birth: *
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Marital Status:
Education:
Gender:
Address: (Street Name, City, State, Zipcode, Country) *
Telephone/Whatsapp:
Social Media:
Question 1: Were you a wanted child trom the conception?

Question 2: How did your birth go? lf possible, ask for details such as a forceps delivery, a vacuum extraction delivery, a nuchal card, an induction, a stay in the NICU, being barn to an early or late delivery etc.

Question 3: What do you know about the age between 0-7 years? Is it often said in conversations that you were, for example, a crying baby? Has anyone close ever passed away? Have you ever experienced a divorce of your parents? Have you ever been bullied at school or do you suffer trom abandonment anxiety, etc.?

Question 4: What do you know about your teenage years? Have there been any social problems at school, such as bullying, being lonely, or negative treatment from teachers, etc.?

Question 5: In the last 20 years, have any special (positive or negative) events occurred in your life?

Question 6: Have you ever been admitted to a hospital / undergone any surgeries?

Question 7: Do you have any heart problems, high/low blood pressure, or other medical conditions that we should be aware of for your own safety? lf so, please let us know.

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Question 8:  Are there any beloved people seriously ill or deceased?

Question 9: Are you addicted or addiction-prone? Such as drugs, alcohol, food, sex, gaming, etc.?

Question 10: Have you used medication, or are you currently using medication? lf so, what medication and for what purpose? Please make sure to check with your pharmacist or doctor to see if this medication can be taken with a MAO-inhibitor, and let us know (this also includes nasal spray, pain medication, vitamins, etc).

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Question 11: Have you been vaccinated for Covid within 2 weeks of the start of the session/ceremony/training? lt is not important to us whether you have been vaccinated or not.

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Question 12: Do you have any physical, mental illness, or family issues such as psychosis, borderline, rheumatism, addictions?

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Question 13: Are you under treatment trom a therapist such as a doctor, psychologist, psychiatrist, or otherwise?

Question 14: What is your living situation? Living alone, with a partner, children, or something else?

Question 15: Are you satisfied with your current living situation?


Question 16: Describe in your own words your problem or complaint.

Question 17: Briefly describe what your problem or complaint is about. What is the cause? What circumstances and developments are involved?

Question 18: Have you ever used drugs? Cannabis, ecstasy, or anything else?

Question 19: Have you ever before used psychoactive substances? And if so, what was your experience? (truffles, psilocybin mushrooms, ayahuasca, bufotenin, etc.)

Question 20: What do you expect trom this retreat/ceremony/session?

Question 21: Are there any physical or emotional peculiarities that are important for us to know?

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Thank you for filling out. We will handle this confidentially.
A copy of your responses will be emailed to the address you provided.
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