Ceremony Application

Please ensure you disclose all information about your current and past medical history, honestly and openly. It will help us greatly in your treatment. All your information will remain confidential only shared within our facilitators. Knowing about your overall health, medical history, and medicine use allows us to understand your current situation and make sure that Psilocybin is safe for you. We will contact you shortly after receiving your form to discuss the process. All information remains strictly confidential and will only be shared with our facilitators.

Name

First Name

Last Name

Birthdate

YYYY

Address

Referred By

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone Number

Which ceremony date are you wanting to join?

YYYY

Please State your personal reasons for your participation.

Please indicate your experience with regards to plant medicine.

Have you ever spent any time with a shaman or other practitioner of Plant Medicine?

Medical History

Our ceremonies are primarily a spiritual undertaking and although personal growth can occur, the experience should not be seen nor is it designed to be a substitute for psychotherapy, psychiatric or other medical care. These ceremonies are not appropriate for persons with certain medical conditions or for persons using certain medications. If you have any doubt or concerns about whether you should participate, consult with the organizer before attending. Please answer the following questions completely and honestly. Please elaborate on yes answers. Do you have a past history of, or currently suffering from any of the following:

Have you ever been hospitalized for psychiatric reasons?

Are you currently in therapy or involved in any type of support group?

Have you ever had any type of seizure?

Have you ever taken SSRI or SNRI medication for depression?

Are you currently pregnant or breastfeeding?

Anything else about your physical or emotional status of which we should be aware?

List any medications you have taken in the past 12 months.

(Prescribed or over the counter Please include dosage and frequency taken. **Please note it is imperative that you provide an accurate and detailed list of medications. )

List supplements (herbs or vitamins) you have taken regularly in the past 12 months.

List any recreational substances that you have taken over the past 12 months.

(Including alcohol and marijuana. Please include frequency of use. **Please note it is imperative that you provide an accurate and detailed list of medications.)

List any allergies.

In which way are you interested in integration support?

Private - Pre and Post Ceremony Integration Support

I am not sure, I would like more information please.

I am not interested at this time.

I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good. I the undersigned hereby seek to participate in meditation with Brandy Nielson and her team. I understand Brandy and her team seeks to ensure the safety of all participants. I am assured that the information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the ceremonial weekend and in meeting my needs before, during and after the ceremony. I have been informed of the nature of the medicine, the needed preparation, and the rules of the ceremony. I commit myself to stay in the circle until the end of the meditation and to respect the directives given by the organizers, helpers, and leader(s) of the ceremony.

Type your full name

Ceremony Application

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