Name
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First Name
Last Name
Email
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Phone
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Date of Birth
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DD
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone
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Emergency Contact Relationship
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1. Please share all current medical conditions you have.
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2. Please share any medications you are taking, or are prescribed - even if you are not taking them.
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3. Do you have a history of seizures, epilepsy, or heart conditions?
4. Have you ever been diagnosed with a psychiatric condition (e.g., schizophrenia, bipolar disorder, PTSD)?
5. Are you currently seeing a therapist, psychiatrist, or other healthcare professional? If yes, please describe what you’re being treated for and what your treatment plan is.
6. Have you experienced any (sexual) trauma? If yes, can you elaborate? (If you prefer to share this in person with us, please indicate yes, and we will speak with you personally)
7. Have you ever been hospitalized for a psychiatric condition?
8. Have you experienced any of the following conditions or tendencies? (Doesn't have to be a formal diagnosis.) Please check all that apply and elaborate where needed.
Other (please specify):
9. Is there anything else about your health that we should be aware of?
Which substances with which approximate dosage
How were your experiences during the session?
How were your experiences afterwards/in integration?
Have you ever experienced a bad trip? If yes, please elaborate.
Have you taken any non-psychedelic drugs in the past 4 months? If yes please list date, frequency and experience.
Take a moment to reflect back on the intention you’ve set for your full Soul Immersion.
Connect with it as deeply as you can and let us know if anything has changed, or needs to be shared about your intention for this ceremony in particular:
Is there anything else you want to share, so we can fully support you during our ceremony?
I affirm that the information I have provided is accurate to the best of my knowledge. I understand this form is confidential and will only be shared with the Ohana Sage team to support the best care during my ceremony.
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