Intake Form | Souls Church

SACRED CEREMONY QUESTIONNAIRE FOR NEW PARTICIPANTS

Thank you for your interest in joining us for this sacred work of transformation and healing.

SOULS mission is to assist all beings in awakening to their divine nature through direct spiritual experience, so they may live, grow, and serve with love, purpose, joy and peace.

Please fill out this questionnaire to make sure that your general health, medications and supplements are compatible with our sacrament. Unlike some other plant medicines, our sacrament is not safe to use with certain medications, or it may be necessary to observe a waiting period before your journey. Other psychoactive substances can block nerve receptors in the brain and may need to be temporarily discontinued to get the full benefit of our medicine.

Everything you share will be held in the strictest confidence. Once you submit this form, we will contact you for a phone interview to review your information and to answer any questions you may have.

General Information

First name

Last name

Phone Number

Birthday

Month

Day

Year

Height & Weight

Current City/State

Emergency Contact Information

Name

Phone Number

Relationship to you

General Questions

Which Ceremony dates are you interested in?

Who referred you to us, or how did you hear about our circle?

What other plant medicines or psychoactive substances (such as psilocybin, peyote, MDMA, DMT, ketamine, LSD, etc.) have you worked with?

Please say a few words about your intentions for working with our sacrament:

This work can be spiritually, emotionally, and physically challenging. How do you feel you are appropriately resourced to integrate this type of change in your life?

Health History

Do you have any regular regimen of plant medicines, psychedelic or not, such as vape pens, micro-dosing or mini dosing? If yes, what are they?

Have you taken antidepressants, anti-anxiety medications, opioids (pain meds), sleep medications, or blood pressure medications in the last four months or will you be taking any of these before or around the time of your ceremony? If yes, what are they?

Have you taken any prescription medications, over-the-counter drugs, antihistamines, or anti-asthma medications in the last three months or will you be taking any of these before or around the time of your ceremony? If yes, what are they?

Are you currently taking any calming or mood altering supplements, such as St. John’s Wort, 5-HTP, Kava, Rhodiola Rosea, Ephedra, Valerian, Kanna, or similar? If yes, what are they?

Are you taking any other supplements (herbal, homeopathic, vitamins, minerals, etc.)? If yes, what are they?

Are you taking or have you taken any of the following: benzodiazepines, cocaine, heroin, methamphetamine, opiates, alcohol, cannabis, or any similar substances? If yes, what are they?

Have you ever had issues with the following mental-health conditions: anxiety disorder, clinical depression, bipolar disorder, borderline personality disorder, dissociative identity disorder, schizophrenia, or schizoaffective disorder? If yes, describe:

Do you have any cardiovascular disorders or issues with blood pressure (high or low)? If yes, please describe.

Have you blacked out or been under anesthesia? If so, how long has it been since?

Is there anything else we should know about your physical or mental condition? If yes, please describe.

IMPORTANT! PLEASE NOTE:

If your medications or other significant health circumstances change between the time you fill out this form and your ceremony begins, please be sure to let us know! There may be an important contraindication or other reason to postpone your ceremony. Anti-depressants and similar MAO Inhibitor drugs are particularly risky. Our intention is always to keep you safe and minimize any risk of harm.

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