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Sacred Counsel - Health Intake
The first step to preparation is getting medically and psychologically cleared. Please take a moment to fill out this form.

Medical History

Have you ever been diagnosed with, or suspect you migt be suffering from any of the following?
Have you ever been hospitalized for any of the above?
Are you currently taking any prescribed medications?
Are you currently taking nutritional or herbal supplements?
Do you have a family history of any of the above mentioned conditions?
Have you ever received professional psychotherapy?
Have you ever had issues with you blood pressure?
Do you have any severe or potentially life-threatening allergies that would require the use of an Epi-Pen?

Alcohol, Addiction, and Drug Use

Have you ever been diagnosed, treated, or self-identified with a substance use dis-harmony (disorder)?*

Psychological History

Have you experienced or been diagnosed with any of the following? Click all that apply.
Do you have a family history of any of the above mentioned conditions?
Have you ever experienced a psycedelic medicine before?


Informed Consent

I have and will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing or will undergo between now and my ceremony.
I will follow dietary, health, and lifestyle guidelines prior to the ceremony
I understand that I may need to stop prescribed pharmaceuticals and/or supplements 30 days prior to the ceremony for safety reasons
I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications.
Do you have an emergency contact and are they aware you are attending ceremony?
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