SSS Client Questionnaire

Sacred Space Sanctuary

Participant Questionnaire
First of all, I just want to take the time to congratulate you for taking the first step to your Divine healing! This is a huge step! I 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 Name Last Name
Are you 18+? *

Yes No
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
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 Disease Low Blood Pressure Allergies Anxiety Disorders Food Sensitivities Heart Problems Circulatory Problems Depression Addiction Hypoglycemia Cancer / Tumor Headaches/Migraines Joint/Muscle Pain Asthma Diabetes Eating Disorder Claustrophobia Meningitis Epilepsy Physical Disability Aneurysm Chronic Pain Fibromyalgia Head Injury Neurological Disease Infectious Disease Gynaecological Condition Other
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 & Current Prescriptions & Dosage
How would you describe your spiritual beliefs / practices, if any?
Check all that apply

I have experienced crystal healing before I have experienced a Reiki session before I have had an energy balancing session before I know about chakras I have used holistic remedies before I have a spiritual path that I am consciously follow I have experienced trauma I have difficulty adjusting to new situations and or people I am generally uncomfortable with touch I am generally uncomfortable expressing myself I love myself I accept myself I am comfortable expressing myself I feel like I belong I have experience with Sacred Plant Medicine
When are you interested in participating in our Sacred Ceremony?
Ceremony Options: (Please Select)
Have you worked with Sacred Plant Medicine before?

Yes No
Which medicine(s)? When?
Are you interested in Preparation & Integration Coaching for an additional cost?

Yes No
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..
Please describe your current living and work situation; please note if you are studying or working, your profession and describe the home environment that you will be returning to after your time with us. This information is important so as we can do our best to prepare you for returning to your home life after your sacred medicine journey with us.
Is there anything else you want to share?
Client Name *
Emergency Contact Name *
Emergency Contact Phone Number *
Signature of Client or his/her personal representative *

Clear
Date *

Month Day Year
Date
This form has been created and will be confirmed by Sacred Space Sanctuary (the authorized representative of this office or practice)
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Sacred Space Sanctuary