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DO NOT USE - Getting to know you

The following form is of the utmost importance. It is an opportunity for me to understand more about your life up until this point and the journey that has led you to this sacred container. Please take some time, for yourself, and for our work together (approx. 10-20 minutes) to complete this form so that we can be set up in the most powerful way to work together. 

Eternal Love, 

Click the button below to start.

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Contact Details

Please complete all information requested. 

Question 2 of 36

First & Last Name:

Question 3 of 36

Preferred Pronouns:

Question 4 of 36

Email:

Question 5 of 36

Phone Number: 

Question 6 of 36

Place of Birth:

Question 7 of 36

Date of Birth:

Question 8 of 36

Occupation:

Question 9 of 36

How did you hear about me?

Question 10 of 36

Emergency Contact Name & Relationship: 

Question 11 of 36

Emergency Contact Phone:

Question 12 of 36

Body Weight (for Dosage):

Question 13 of 36

Dietary Restrictions:

Family background and Relationships

Please briefly describe your relationships with your: 

Question 15 of 36

Family of origin (parents and siblings) historically and the present:

 

Any key dynamics, roles, stories, incompletions, areas of wounding, and also areas of empowerment, strength, legacy, and resources.

Question 16 of 36

Current family/ relationships:

What are the close relationships in your life?

How do you describe them?

Are they fulfilling / challenging & Why?

Question 17 of 36

Community:

Do you belong to a community?

Do you feel nourished or exhausted by social commitments?

Therapeutic & Medicinal Background

Please briefly describe past and current therapeutic experiences: 

Question 19 of 36

Prior experience: Please list any / trainings / certifications / relevant experience you have in the healing arts.

Question 20 of 36

Have you been to therapy? If so, please list past or present healing modalities or psychological work you've engaged in.

Question 21 of 36

What are the focus areas and themes throughout your healing/ therapeutic experiences, past or present?

Question 22 of 36

Have you ever been hospitalized for psychiatric treatment including a manic-depressive disorder, or psychotic break? Severe depression?

Question 23 of 36

Are you presently on any MAOIs or anti-depressants?

 

Examples - Nardil (phenelzine), Parnate (tranylcypromine), Marplan (isocarboxazid), Eldepryl (l-deprenyl), and Aurorix / Manerix (moclobemide)

A

Yes

B

No

Question 24 of 36

Important:

Are you currently on any medications or supplements?

 

If yes, please list all medications and supplements you are taking, your dosage, and for how long you have been taking each. 

 

Question 25 of 36

Do you have prior experience with MDMA?

 

A

Yes

B

No

Question 26 of 36

If you answered yes to the question above, do you know your dosages and what amount have you taken in the past? 

Question 27 of 36

If yes, please describe any past experience with MDMA either, recreational, ceremonial, or therapeutic.

Question 28 of 36

Do you have prior experience with other psychedelic medicines? 

A

Yes

B

No

Question 29 of 36

If you answered yes to the above question please list what other psychedelic medicines you have used and your experiences with them. 

Question 30 of 36

If yes, please describe any past experience with MDMA either, recreational, ceremonial, or therapeutic.

Intentions & Practices

If yes, please describe any past experience with MDMA either, recreational, ceremonial, or therapeutic.

Question 32 of 36

In what ways do you nurture your spiritual and personal growth and development?

What regular practices support you in this (mindfulness, physical, religious, etc.)?

Question 33 of 36

What is your intention for doing this work and what is calling you to this sacred container? 

Question 34 of 36

What are you grateful for?

What do you value the most in your life?

Question 35 of 36

Is there anything else you would like me to know about you to help me to support you in the best way possible?

Question 36 of 36

(When in person) Are you interested in receiving energy work from Sand? 

Note: this may include physical touch

A

Yes

B

No, not at this time

Confirm and Submit