Participant Intake Form

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.

Personal Information

Full Legal Name *

First

Middle

Last

Preferred Name (if different)

Date of Birth *

Age *

Mobile Phone # *

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact Name *

First

Last

Emergency Contact Phone # *

Relationship to Emergency Contact *

Which Sacred Sacrament(s) Are You Interested In Receiving? *

Which Ceremony Are You Interested In Attending? *

Have you previously participated in a sacramental, psychedelic, or entheogenic ceremony? *

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

What is calling you to participate in this sacramental experience? *

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)? *

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? *

Does your immediate family support your 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? *

Trauma in CHILDHOOD? *

Trauma in ADULTHOOD? *

Significant losses or grief? *

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 breastfeeding, pregnant, or maybe be pregnant? *

Breastfeeding
Pregnant
N/A

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

Have you been hospitalized for a medical condition within the past 12 months? *

Has any immediate family member (parent, sibling, or child) been diagnosed with any of the following? *

Are you currently under the care of a psychiatrist, psychologist, therapist, or counselor? *

Have you experienced suicidal thoughts within the past 12 months? *

Have you ever attempted suicide? *

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

Please explain any answers above that may require additional context:

Please list ALL medications, supplements, hormones, peptides, injections, and substances you are currently taking:

Have you ever had a substance abuse issue? *

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

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

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

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

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

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

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

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 have not have been diagnosed with a personality 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

Would you like to join our mailing list?

Please use this space to share any additional questions, concerns, intentions, or information you would like Temple of Eden to know.

Questions and Concerns

Medical Disclaimer & Acknowledgement

The Temple of Eden and its representatives are not licensed medical professionals and do not provide medical advice, diagnosis, treatment, or healthcare services.

Any information shared before, during, or after ceremony is offered solely for educational, spiritual, and informational purposes and should not be interpreted as medical advice.

Participants should never discontinue, adjust, or modify prescribed medications without first consulting their prescribing physician or qualified healthcare provider.

Participation in ceremony is not intended to diagnose, treat, cure, or prevent any physical or mental health condition.

By participating, you acknowledge that you are responsible for your own healthcare decisions and agree to consult appropriate medical professionals regarding any medical concerns, conditions, or medications.

You certify that all information provided is truthful, accurate, and complete to the best of your knowledge.

I have read and understand Temple of Eden's Medical Disclaimer. *

I have read and understand Temple of Eden's Medical Disclaimer.

I understand Temple of Eden is not providing medical advice or healthcare services. *

I understand Temple of Eden is not providing medical advice or healthcare services.

I agree to consult my physician regarding medications and medical conditions. *

I agree to consult my physician regarding medications and medical conditions.

I certify that the information provided is accurate and complete. *

I certify that the information provided is accurate and complete.

I understand that withholding relevant medical or psychological information may place me at risk. *

I understand that withholding relevant medical or psychological information may place me at risk.

I understand that participation in sacramental ceremonies is entirely voluntary, and that completing this form does not guarantee acceptance into a ceremony. Temple of Eden reserves the right to postpone, reschedule or decline participation if safety concerns arise. *

I understand that participation in sacramental ceremonies is entirely voluntary, and that completing this form does not guarantee acceptance into a ceremony. Temple of Eden reserves the right to postpone, reschedule or decline participation if safety concerns arise.

Signature *

Clear Signature

Date / Time *

TEMPLE OF EDEN

SACRAMENTAL PARTICIPATION AGREEMENT, INFORMED CONSENT, ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND HOLD HARMLESS AGREEMENT

Please read this document carefully. By checking the agreement checkbox below, you acknowledge that you have read, understood, and voluntarily agree to all terms contained herein.

Eligibility

I certify that I am at least twenty-one (21) years of age and legally capable of entering into this agreement.

I understand that participation in Temple of Eden ceremonies is limited to adults twenty-one (21) years of age or older.

Voluntary Participation

I understand that my participation in any Temple of Eden ceremony, event, retreat, training, gathering, or sacramental experience is completely voluntary.

I understand that I am under no obligation to participate and may decline participation at any time prior to receiving any sacrament.

I acknowledge that I am participating of my own free will and am not being coerced, pressured, or influenced by Temple of Eden, its representatives, or any third party.

Sacramental and Spiritual Nature of Participation

I understand that Temple of Eden is a religious and spiritual organization and that any sacrament offered is provided solely within a spiritual, religious, ceremonial, educational, and personal growth context.

I understand that Temple of Eden does not guarantee any particular outcome, healing, insight, breakthrough, transformation, or benefit.

I acknowledge that spiritual experiences are subjective and may vary significantly between participants.

Medical Disclaimer

I understand that Temple of Eden, Priestess Suzi Kalypso, ministers, facilitators, volunteers, contractors, staff members, and representatives are not licensed medical professionals and do not provide medical advice, diagnosis, treatment, psychotherapy, or healthcare services.

Any information shared before, during, or after ceremony is offered solely for educational, spiritual, and informational purposes and should not be interpreted as medical advice.

I understand that I should never discontinue, adjust, or modify prescribed medications without first consulting my prescribing physician or qualified healthcare provider.

Participation in ceremony is not intended to diagnose, treat, cure, or prevent any physical, emotional, psychological, psychiatric, or medical condition.

I acknowledge that I am solely responsible for all healthcare decisions and agree to consult qualified healthcare professionals regarding any medical concerns, conditions, medications, or treatment plans.

Disclosure of Health Information

I certify that all information provided in my intake forms, screening documents, questionnaires, and communications with Temple of Eden is truthful, complete, and accurate to the best of my knowledge.

I understand that withholding information regarding medical conditions, psychiatric conditions, medications, supplements, substance use, or personal history may increase the risk of adverse outcomes.

I agree to immediately notify Temple of Eden of any changes to my physical health, mental health, medications, supplements, or circumstances prior to participation.

Assumption of Risk

I understand that participation in sacramental ceremonies may involve substantial, serious, and unforeseeable risks.

These risks may include, but are not limited to:

Intense emotional experiences
Intense psychological experiences
Altered states of consciousness
Physical discomfort
Elevated blood pressure
Changes in heart rate
Anxiety
Fear
Panic
Confusion
Dizziness
Loss of balance
Nausea
Vomiting
Emotional release
Recollection of traumatic memories
Psychological distress
Spiritual crisis
Physical injury
Falls
Aggravation of known or unknown medical conditions
Unexpected reactions
Serious injury
Permanent disability
Death

I acknowledge that no screening process can eliminate all risks. I knowingly and voluntarily assume all known and unknown risks associated with my participation.

Emergency Medical Care

In the event of an emergency, I authorize Temple of Eden and its representatives to seek emergency medical assistance on my behalf if deemed necessary.

I understand that I am solely responsible for all costs associated with emergency medical treatment, transportation, hospitalization, physician services, and related expenses.

Release of Liability

TO THE FULLEST EXTENT PERMITTED BY LAW, I HEREBY VOLUNTARILY RELEASE, WAIVE, DISCHARGE, AND FOREVER HOLD HARMLESS:

TEMPLE OF EDEN, PRIESTESS SUZI KALYPSO, ALL MINISTERS, FACILITATORS, VOLUNTEERS, CONTRACTORS, EMPLOYEES, OFFICERS, DIRECTORS, AGENTS, REPRESENTATIVES, SUCCESSORS, ASSIGNS, THE OWNER OF ANY PROPERTY WHERE A CEREMONY, EVENT, TRAINING, RETREAT, OR GATHERING IS HELD, ANY LANDLORD, PROPERTY MANAGER, HOST, OR VENUE PROVIDER, AND ALL RELATED INDIVIDUALS OR ENTITIES

FROM ANY AND ALL CLAIMS, DEMANDS, CAUSES OF ACTION, DAMAGES, LOSSES, INJURIES, LIABILITIES, COSTS, EXPENSES, ATTORNEY FEES, OR LEGAL ACTIONS OF ANY KIND WHATSOEVER ARISING FROM OR RELATED TO MY PARTICIPATION.

THIS RELEASE APPLIES TO ALL CLAIMS, INCLUDING CLAIMS ARISING FROM NEGLIGENCE, TO THE MAXIMUM EXTENT PERMITTED UNDER APPLICABLE LAW.

Covenant Not to Sue

I AGREE THAT I SHALL NOT FILE, INITIATE, PARTICIPATE IN, OR MAINTAIN ANY LAWSUIT, CLAIM, COMPLAINT, ARBITRATION, ADMINISTRATIVE ACTION, OR LEGAL PROCEEDING AGAINST:

TEMPLE OF EDEN, PRIESTESS SUZI KALYPSO, ANY FACILITATOR, VOLUNTEER, STAFF MEMBER, MINISTER, PROPERTY OWNER, LANDLORD, HOST, VENUE PROVIDER, OR ANY RELATED PARTY

FOR ANY CLAIM ARISING OUT OF OR RELATED TO MY PARTICIPATION IN A TEMPLE OF EDEN CEREMONY OR EVENT. I UNDERSTAND THAT THIS PROVISION IS A MATERIAL CONDITION OF MY PARTICIPATION.

Indemnification

I agree to defend, indemnify, and hold harmless Temple of Eden, Priestess Suzi Kalypso, ceremony facilitators, property owners, venue providers, volunteers, and all related parties from any claims, damages, liabilities, losses, attorney fees, or expenses arising from my actions, conduct, participation, omissions, or breach of this agreement.

Media Release

Note: You will be asked to select your media authorization options directly on the application form questions below.

Refund Policy Acknowledgment

I understand and acknowledge that all ceremony registrations, donations, contributions, tuition payments, retreat payments, deposits, and event fees are subject to Temple of Eden's refund, cancellation, and rescheduling policies.

Governing Law

This agreement shall be governed by the laws of the State of California. If any provision of this agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Participant Acknowledgment

By checking the mandatory agreement box below, I acknowledge that:

I am at least 21 years of age.
I have carefully read this entire agreement.
I fully understand its contents.
I understand that I am waiving important legal rights.
I voluntarily assume all risks associated with participation.
I voluntarily release Temple of Eden, Priestess Suzi Kalypso, ceremony facilitators, venue providers, and property owners from liability.
I voluntarily agree not to sue any released party for claims arising from my participation.
I sign this agreement freely, voluntarily, and without coercion.

Signature *

Clear Signature

Date / Time *

MEDIA RELEASE *

I authorize Temple of Eden to use photographs, video recordings, testimonials, and media containing my likeness for educational, archival, promotional, community, and marketing purposes.
I do not authorize the use of my likeness or image.

Add to mailing list *

Keep me connected to the Temple of Eden for future community events, ceremonies, retreats, integration and more.

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

Drag & Drop Files, Choose Files to Upload

Personal Information

Please provide your preferred PRIVATE ceremony date(s):

Please specify which sacrament(s) and approximately when

Have you ever experienced any of the following:

Medical Information

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

Please check all medications, supplements, hormones, or substances you currently take.

Please select the response that best describes you:

Please use this space to share any additional questions, concerns, intentions, or information you would like Temple of Eden to know.

Medical Disclaimer & Acknowledgement

Medical Disclaimer & Acknowledgement

SACRAMENTAL PARTICIPATION AGREEMENT, INFORMED CONSENT, ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND HOLD HARMLESS AGREEMENT

Eligibility

Voluntary Participation

Sacramental and Spiritual Nature of Participation

Medical Disclaimer

Disclosure of Health Information

Assumption of Risk

Emergency Medical Care

Release of Liability

Covenant Not to Sue

Indemnification

Media Release

Refund Policy Acknowledgment

Governing Law

Participant Acknowledgment

Participant Intake Form

Personal Information

Please provide your preferred PRIVATE ceremony date(s):

Please specify which sacrament(s) and approximately when

Have you ever experienced any of the following:

Medical Information

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

Please check all medications, supplements, hormones, or substances you currently take.

Please select the response that best describes you:

Please use this space to share any additional questions, concerns, intentions, or information you would like Temple of Eden to know.

Medical Disclaimer & Acknowledgement

Medical Disclaimer & Acknowledgement

SACRAMENTAL PARTICIPATION AGREEMENT, INFORMED CONSENT, ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND HOLD HARMLESS AGREEMENT

Eligibility

Voluntary Participation

Sacramental and Spiritual Nature of Participation

Medical Disclaimer

Disclosure of Health Information

Assumption of Risk

Emergency Medical Care

Release of Liability

Covenant Not to Sue

Indemnification

Media Release

Refund Policy Acknowledgment

Governing Law

Participant Acknowledgment

Refund Policy

Medical & Ethical Harvesting Disclaimers