Yemaya Moon Spiritual Church
Plant Medicine Ceremony Questionnaire

We send out this questionnaire so we can support you in the most optimal way. Please fill out the questionnaire honestly and as precisely as possible. Please let us know about any health-related issues with you and your family, past, and present. This will not mean you can’t participate in a retreat or program, we need it for your safety, and so we can customize our service to you and your unique situation. 

FULL SCHEDULE IS ON OUR WEBSITE.
 


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Email *
Name *
Phone Number *
Age *
Gender *
Nationality *
Occupation *
Any special dietary restrictions or allergies? *
Emergency Contact name, phone number and email  *
Do you have previous experience with sacred plant medicine? If so please elaborate in detail. *
Do you have any previous experience with psychedelic substances? If so, please elaborate in detail. *
Do you have any psychic sensitivities, medium abilities, astral travel, lucid dreams, empathic sensitivities?
 *

Do you have any existing practices or ties to any shamanic tradition, familiar or initiated?

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Do you practice any martial art, or have served time in the military?

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Have you ever been diagnosed with a medical condition during your lifetime? If so, please indicate them below. *
Have you or anyone in your family ever been diagnosed with a mental health disorder? If so, please elaborate. *
Are you currently taking any prescription or over the counter medications? If so, please list them with name and dosage. *
Have you ever been institutionalized for any reason? Rehab included. (when, for how long)
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Certain medications are not compatible with plant medicine therapies and can cause illness up to and including death. Do you understand the importance of being truthful about your responses? *
Do you have any substance dependency/addictions? If so, please elaborate.
 *
 Do you suffer from panic attacks, any phobias or major fears? (how severe, how often and last time)
 *
Do you suffer from asthma, COPD, CHF or chronic respiratory issues? If so, what is your medication regimen? *
 Do you have or have had any chronic illnesses in your life, any heart issues at all? If so, please elaborate.
 *
Is there a family history of heart issues? *

 Have you had surgical operations in your life? (which kind, when)


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Do you suffer from any chronic pain – physical, or have had major emotional or physical traumas in your life?

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Do you use spiritual practices, religious or otherwise, such as meditation, yoga.


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Do you have access to an emotional support structure at home?

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What are your desires to achieve/open/heal/address during this program/ceremony?
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Do you consider yourself a physically healthy, and mentally healthy person?
 *
Describe the quality and quantity of love in your life?
 *
Again…any medications? Anti depressant, allergy, sleep, asthma, epilepsy, thyroid, sedative…Anything! Please write here.
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Do you regularly use any recreational drugs in your life? Are any of these habitual? Alcohol and marijuana included. (which, for how long and last time usage)
 *
Please list a few hobbies, joys in your life.
 *
Describe your relationship to nature.

*
How were you introduced to plant medicine? *
If you have been in plant medicine ceremonies in the past please share some of your experiences. *
What is your number one reason  for wishing to sit in ceremony? *
Are there any other applicants that you have a preference in sitting with? *
If invited to ceremony do you agree to follow pre and post ceremony guidelines? These will be shared after deposit has been received. *
How did you learn about our church and services? *
In order to maintain the integrity of our church we request that you only refer individuals that have good character. Someone that you trust and would take home to meet your grandma. Do you agree to be diligent with sharing? *
Based on the current schedule do you have a preferred ceremony date? Please list two dates. *
Are you interested in a single night ceremony or a two day retreat? *
If choosing the one night option, will you be joining us for healing circle the day after? *
Have you ever experienced an adverse reaction to plant medicine including, marijuana and psychedelics? If so, please elaborate. *
Our Curandera was trained in the Shipibo tradition and sings in said language as well as English and Spanish. There will also be prerecorded music playing towards the latter part of the ceremony. Do you understand that ceremony is eclectic in nature? *
Do you have a reliable source of transportation to and from location? We are located in Sussex County, NJ. Location address will only be disclosed to those parties that are invited to ceremony.  *
Medications are extremely important. Have you listed all of your medications and dosages? If not, please add them here. *
Tell us about your most spiritual experience so far? *
Is there anything else that you feel is worth sharing about yourself? *
If invited to ceremony you will be contacted by email with deposit instructions. Deposits must be received within 5 days of acceptance email receipt. Do you agree to comply with request? *
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