First Name

Last Name

Phone *

Email *

What is calling you to this work right now? (What are you hoping to heal, release, or remember? Please share honestly — there’s no right answer.)

Have you experienced any previous ceremonial or plant medicine work? (If yes, please list which sacraments or modalities and when. If no, share your relationship to spiritual or healing work so far.)

Do you have any medical or mental health conditions we should be aware of?

Are you on medications and if so which ones?

Are you currently under the care of a therapist, psychiatrist, or other healing practitioner? (If so, please describe how they support you. This helps us understand your integration network.)

How do you currently support your body and nervous system in times of challenge? (Examples: breathwork, journaling, movement, prayer, therapy, nature, etc.)

Are you seeking a private immersion or a group ceremony experience? (Please describe what feels most aligned for you at this time and why.)

Is there anything else you’d like to share about your journey, intentions, or readiness for this work? (You may include any fears, curiosities, or desires that feel alive.)