Gender* Gender* Woman Man Other

First Name*

Last Name*

Date*

Date of Birth*

E-mail Address*

Phone Number*

Weight*

Height*

What is your purpose for seeking Sacred Animal Medicine?*

Which medicine are you interested in working with? Kambo or Bufo?*

Have you read the information pertaining to this medicine, provided by your practitioner?*

Do you feel that you are mentally prepared to handle any after effects of working with this medicine?*

Are you physically in a position to work with this medicine (as outlined in the info sheet)?*

Have you worked with Psychedelics in the past? If so, which substance? Please provide a brief description of your experience and how it has impacted your life.*

Do you have any current medical conditions?*

Do you take any medications? Please list each pharmaceutical and what it is used for.*

Do you suffer from high or low blood pressure? Do you take medication for this condition?*

Do you currently or have you ever suffered from seizures?*

Do you experience pain on a daily basis? If so, where in your body? Please rate the level of pain from 1-10.*

Do you have any allergies? Please explain.*

How many hours of sleep do you get in a night?*

Do you wake up feeling refreshed?*

Do you currently (past 3 months) or have you ever been addicted to a substance? Please explain.*

Do you have any current or past psychological or psychiatric conditions or diagnoses? If so, please describe.*

Do you suspect that you have an undiagnosed mental health issue?*

Have you ever tried to commit suicide or had suicidal thoughts? Please explain.*

Have you ever engaged in self-harm or destructive behaviour to yourself or another?*

Do you currently see a psychiatrist, psychologist or counsellor? How often?*

Have you ever been hospitalized for a psychotic episode?*

Have you experienced any trauma that you are aware of? Please explain.*

Have you ever been abused physically, mentally, emotionally or sexually? Please explain.*

Have you ever experienced spiritual abuse (with a religion or cult)? Please explain.*

Do you ever experience extreme anxiety, fear or paranoia? Please explain.*

Do you have trust issues? Please explain.*

Plant and Animal Medicines can shake things up in a person’s life. Are you in a place where you can handle some instability for awhile?*

Do you have any spiritual or contemplative practices to help you navigate through the emotional, mental and physical shifts that will likely occur after a treatment?*

What are your coping mechanisms and self-care practices that help you deal with stress and challenges in life?*

Do you feel comfortable asking for help, if needed?*

Do you have a support system to rely on when life becomes difficult? Please list any persons you feel you can count on and their phone numbers.*

Do you have a person or network of people to assist you integrate this type of work?*

What groups or communities are you a part of?*

Is there anything else you want to share about yourself?

Do you speak English?* Do you speak English?* Yes No