Medicine Lodge Intake

The following information is collected to assess suitability of participation in this ancestral ceremony. We take as much precaution as possible to ensure a positive experience for each of the participants and facilitators. Please note that this is a safe and compassionate space and in the case that someone is not suitable for this experience, we will do our best to suggest alternative approaches to wellness.

All information is confidential, only to be shared with the event organizer and ceremony facilitator.

First Name

Last Name

Do you have any experience with other plant medicines? If so which ones and how often?

List any recreational drugs, including alcohol, and frequency.

List any prescribed pharmeceuticals, including frequency and reason.

Do you have any history with mental illness? Do your family members have any history with mental illness? If so, please describe.

Do you have a history with PTSD or anything that could be considered a traumatic event? Especially Physical/ sexual abuse?

Do you have any pre-existing medical conditions? Do members of your family have any history with medical conditions?

Do you have any food allergies?

And lastly but most importantly what is/are the reason(s) you would like to attend?

Medicine Lodge Intake

All information is confidential, only to be shared with the event organizer and ceremony facilitator.

kyle@connectionintegration.com