Participant Intake Form - Temple of Eden

- Step 1 of 2

The following form helps us understand a little bit more about you and how we can best ensure that you have a meaningful and safe experience during our sacred healing ceremonies. Please take into consideration that this is a religious ceremony, not a medical or wellness procedure or facility.

All members must complete an intake form prior to attending ceremony. First time participants will be required to complete an additional screening via phone call.

All of your responses are entirely confidential. Please read each question and answer carefully. If you would prefer not to answer a question, please leave it blank.

Participant Information

Legal Name *

First

Last

Preferred Name (if different)

Email Address *

Would you like to join our mailing list?

Mobile Phone # *

Emergency Phone # *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How did you hear about Temple of Eden?

Facebook
Instagram
Website
Participant Referral

Please provide your Instagram handle/name.

This is usually something like "@YourUserName"

Please provide First and Last name of person that referred you *

First

Last

Have you ever attended a Bufo ceremony before?

How many times have you attended a Bufo ceremony? *

Have you ever attended a Bufo ceremony with Temple of Eden and/or Suzi Kalypso?

Please provide date and City,State in which you attended a Bufo ceremony with Temple of Eden and/or Suzi Kalypso?

Date *

City, State *

Are you interested in a private session or group ceremony? *

Private Session
Group Ceremony

What date are you interested in booking? *

Please briefly state your reasons for seeking to attend a sacred healing ceremony with Temple of Eden

What are your current life challenges?

Are there any trauma triggers that you would like us to be aware of (such as; touching, loud noises, tight spaces, shouting, drumming, high pitched noises or others)?

Please explain trauma triggers that you would like us to be aware of *

What would you like to gain from this experience?

What is your occupation?

What are your hobbies/interests?

Who are the most important people in your support network (friends, family, spiritual leaders or community, therapists, etc)?

Is there any area where your support network is lacking?

Please explain what you feel you're missing in your support network. *

Does your immediate family support your having this experience?

Please explain how your immediate family supports you in having this experience

Are you serving or have you served in any branch of the armed forces of the United States?

Are you currently or have you ever been a first responder (peace officer, highway patrol, firefighter, EMT, paramedic, emergency room medical staff, disaster relief worker, social worker, public safety dispatcher)

In what time frame are you looking to attend ceremony?

Immediately
1-3 Months
3-6 Months
More than 6 Months

Have you ever experienced any of the following:

Meditation, consciousness-altering states, or shamanic retreats?

Please explain your experiences with meditation, consciousness-altering states, or shamanic retreats *

Trauma in CHILDHOOD?

Please explain your CHILDHOOD trauma experience(s) *

Trauma in ADULTHOOD?

Please explain your ADULTHOOD trauma experience(s)

Significant losses or grief?

Please explain your significant losses or grief

Please use this section to share any questions or concerns you have.

Questions and Concerns

Medical Information

For health and safety reason you cannot attend a ceremony if have taken SSRIs within 2 weeks, recreational drugs and any medication within 3-4 days, and supplements 24 hours prior to ceremony.

You are ineligible to participate in a sacred healing ceremony if; you are under the age of 21, in your first trimester of pregnancy, you have a history of psychosis and or schizophrenia, have been diagnosed with a personality disorder, current active medicated bipolar disorder, history of seizures or diagnosis of epilepsy, current anorexia and or bulimia, experienced a stroke or embolism, severe asthma or emphysema, a known cardiac illness, or uncontrolled high blood pressure.

Please provide the information requested below, as it may be needed in case of an emergency.

Allergies

Conditions requiring special consideration (medical/physical)

Are you currently pregnant?

Please provide your expected due date: *

Do you currently have a diagnosis of a terminal medical condition?

Please describe your diagnosed terminal medical condition *

Have you ever been hospitalized for any psychiatric or emotional issue?

Reason/Diagnosis for Hospitalization *

Date of Last Hospitalization *

Have you ever had a substance abuse issue?

Yes - Current
Yes - I am sober and in recovery
Yes - Past
No

Please explain your current substance abuse issue *

How long have you been sober? *

Do you take any MAO inhibitors? Examples include Marplan, Nardil, Niamid, Parnate, Jatrosom, and Emsam.

Please provide MAO inhibitor medication name, dosage, and frequency *

Do you use any SSRI’s? Examples include Zoloft, Celexa, Lexapro, Luvox, Paxil, Prozac, Viibryd, and Symbyax

Please provide SSRI medication name, dosage, and frequency *

Do you take any tricyclic antidepressants? Examples include Anafranil, Tofranil, Vivactil, Nortriptyline, Amitriptyline, Imiprex, and Amoxapine

Please provide tricyclic antidepressant medication name, dosage, and frequency *

Do you use an asthma inhaler or take any asthma medications?

Please provide asthma medication name, dosage, and frequency *

Do you use any amphetamines? Examples include Adderall, Ritalin, Concerta, & Vyvanse.

Please provide amphetamine medication name, dosage, and frequency *

Do you take any narcotic pain killers? Examples include Oxycodone, Vicodin, Codeine, Dilaudid, Duragesic (fentanyl), Demerol, Norco, Lorcet, Methadone and Heroin.

Please provide narcotic pain killers medication name, dosage, and frequency *

Are you taking St John’s Wort?

Are you taking any supplements that contain L-tryptophan (essential amino acids)?

Are you currently taking any hormones such as testosterone or estrogen?

Please select the response that best describes you:

I am over the age of 21.

True
False

I do not have a history of psychosis and/or schizophrenia.

True
False

I have not have been diagnosed with a personality disorder.

True
False

I do not have an active medicated diagnosis of bipolar disorder.

True
False

I do not have history of seizures or diagnosis of epilepsy.

True
False

I am not currently experiencing anorexia and/or bulimia.

True
False

I have not experienced a stroke or embolism.

True
False

I do not have severe asthma or emphysema.

True
False

I do not have a known cardiac illness (previous heart attack or stroke, pericardia, heart murmur, etc.).

True
False

I do not have severe uncontrolled high blood pressure.

True
False

To complete your intake form, please upload a valid photo ID.

Click or drag a file to this area to upload.