Giving Tree Medicine

Medicine Assisted Breathwork

Intake Form

Full name

Phone

Emergency Contact and Phone Number

What brings you to partake in this ceremonial space?

What are your intentions for this ceremony?

What is your prior experience with psilocybin mushroom use? Do you currently partake in this medicine? If so, how much ?When? What is your dosage?

Are you currently taking any medication? If so, Why are you taking it? What is the name? Dosage? How much? For how long have you been taking it?

Are you taking any street drugs? Cocaine? Molli? MDMA? Opioids? Meth?

Do you have any retinal detachment issues? Eye pressure issues?

Have you had any surgeries in the past six months?

Do you have a history of aneurysm for yourself or in your family?

Unmedicated high blood pressure?

Do you have epilepsy?

Have you experienced a lot of trauma within the past 12 months? Death of a family member? Divorce? Change in working status? Areas of your life that feel out of control?

Have you had psychotic episodes? Have you become dangerous to yourself and others? When did this happen?(not that this will change anything, I just need to be aware.)

Do you have any particular food, allergies? As this medicine will be served in cacao and in a cacao blend mixed with potentiating herbs and spices.

It is advisable to abstain from the use of any medicines such as cannabis or other forms of Mushrooms for 12 to 24 hours prior to ceremony. Dosages of prescription SSRIs can be modified the day of and resumed afterwards when needed.

Please refrain from eating 6 hours prior to the ceremony.

Bring items to ceremony that help you feel comfortable. Your favorite pillow, blanket, water bottle, crystals, journal all can be present to help you on your journey.

By filling out this worksheet and signing it, you are giving full permission to explore this Medicine on your own terms. All host, places, host owners, space holders, and co-facilitators are completley exempt from any litigation action, that is a result of this ceremony. Giving Tree Medicine, Barbara's gift and Casa Giving Tree as well as myself, Donna Lanni are not responsible or legally obligated in any capacity for any bodily, physical, metal or spiritual miss alignment or accident that is a result of this ceremonial process.

If you need private counseling and integration work following the ceremony, you are invited to reach out and I will provide this for at an additional sliding scale and at a reasonable cost.

AGREEMENT TO FOLLOW DIRECTIONS

I agree to follow any oral instructions or directions given by the practitioners.

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Date

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Giving Tree Medicine

Medicine Assisted Breathwork

Intake Form

AGREEMENT TO FOLLOW DIRECTIONS

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