SPIRIT of Truth NAC Guest Application

Spirit of Truth Native American Church

Sacred Space Sanctuary
First of all, we just want to take the time to congratulate you for taking the first step to your Divine healing! This is a huge step! We know it’s hard to invest in ourselves, we tend to put every one and thing else above our own desires and needs. So, good for you for taking this huge step to discovering your divine bliss!

Please take your time in completing this form so that we can better serve you.
Full Name*

First NameLast Name
Are you 18+?*

YesNo
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Please note that all information (written or obtained during your session) is confidential.
Health History Please Check All That Apply Past/Current (notate any current issues in notes below)

Thyroid DiseaseLow Blood PressureAllergiesAnxiety DisordersFood SensitivitiesHeart ProblemsCirculatory ProblemsDepressionAddictionHypoglycemiaCancer / TumorHeadaches/MigrainesJoint/Muscle PainAsthmaDiabetesEating DisorderClaustrophobiaMeningitisEpilepsyPhysical DisabilityAneurysmChronic PainFibromyalgiaHead InjuryNeurological DiseaseInfectious DiseaseGynaecological ConditionOther
In detail, please explain any medical conditions selected. If there is any additional medical information that you feel we need to be aware of please explain.
Most Recent (within 6 weeks) & Current Prescriptions & Dosage
How would you describe your spiritual beliefs / practices, if any?
Check all that apply

I have experienced crystal healing beforeI have experienced a Reiki session beforeI have had an energy balancing session beforeI know about chakrasI have used holistic remedies beforeI have a spiritual path that I am consciously followI have experienced traumaI have difficulty adjusting to new situations and or peopleI am generally uncomfortable with touchI am generally uncomfortable expressing myselfI love myselfI accept myselfI am comfortable expressing myselfI feel like I belongI have experience with Sacred Plant Medicine
What services are you interested in? (Please Select)
When are you interested in participating in one or more of our Services? (Please Select)
Upcoming Dates For The Sacred Way Weekend Healing Ceremony: Friday - Monday (Multiple Sacraments- Kambo, Rapeh/Hape, Bufo, Ayahuasca) 3 Sacred Sacrament Ceremonies (Please Select)
Have you worked with Sacred Plant Medicine before?*

YesNo
Which medicine(s)? When?
Are you interested in our Sacred Way Lifestyle preparation & integration program for an additional investment?

YesNo
Are you interested in our 6 week virtual psilocybin micro dosing program "Mystical Micro Magick"

YesNo
Are you interested in 9 week Goddess Rising program for an additional investment?

YesNo
If you have not done so, please take some time to reflect deeply on this question. It is very important for us (and you) to clarify what you hope to achieve by participating in ceremony.
Have you experienced what you would regard as a traumatic incident in your past that you would like us to know about? If yes, please provide any additional information below that you feel may be helpful for us in supporting you..
Is there anything else you want to share?
Would you like to be added to our newsletter?*

YesNo
Client Name*
Emergency Contact Name*
Emergency Contact Phone Number*
Signature of Client or his/her personal representative*

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Date*

MonthDayYear
Date
This form has been created and will be confirmed by Spirit of Truth Native American Church (the authorized representative of this office or practice)
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Spirit of Truth Native American Church