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Bufo Intake Form

Participant Intake Form

For the safety of all involved, please answer as honestly and transparently as possible. The more transparent you are in your answers, the better we can cater to your specific circumstances. Rest assured that all correspondence between us is completely confidential. Feel free to contact me directly if you have any questions or concerns.

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:

Preferred Name (if different):

Would you like to join our mailing list? YesNo

How did you hear about our ceremonies? Facebook Instagram Website Participant Referral

Have you ever attended a Bufo ceremony before? YesNo

Have you ever attended a Bufo ceremony with us? YesNo

Are you interested in a private session or group ceremony? Private SessionGroup Ceremony

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)? YesNo

Is there any area where your support network is lacking? YesNo

Does your immediate family support your having this experience? YesNo

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

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)

Yes

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? YesNo

Trauma in CHILDHOOD? YesNo

Trauma in ADULTHOOD YesNo

Significant losses or grief? YesNo

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

Medical Information

For health and safety reason you cannot attend a ceremony if you 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.

Conditions requiring special consideration (medical/physical)

Are you currently pregnant? YesNoN/A

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

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

Have you ever had a substance abuse issue?

Yes - Current

Yes - I am sober and in recovery

Yes - Past

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

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

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

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

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

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

Are you taking St John’s Wort? YesNo

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

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

Please select the response that best describes you:

I am over the age of 21. TrueFalse

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

I have not been diagnosed with a personality disorder. TrueFalse

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

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

I am not currently experiencing anorexia and/or bulimia. TrueFalse

I have not experienced a stroke or embolism. TrueFalse

I do not have severe asthma or emphysema. TrueFalse

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

I do not have severe uncontrolled high blood pressure. TrueFalse

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

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Your legal name

Your email address

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December 18, 2024 11:31 am PST

Bufo Intake Form Uploaded by Kristine Ovsepian - kristine@journeystoheal.com IP 97.107.177.135