Sanctuary of Unified Love Health Screening

Contact & Health Screening

Sanctuary of Unified Love
Brightest Blessings. Thank you for reaching out. This is our contact and health screening form.

Successful Ceremonies and Experiences are only possible when the facilitator has a complete understanding of the initiate - physically, mentally, and emotionally. Please complete this questionnaire as thoroughly as possible. Thank you.
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Residential Location*

CityState / Province
E-mail*
Phone Number*

Area CodePhone Number
How did you find us?
Is there anything you'd like to share in regards to desire, intention, or what you are looking for?
What are you most interested in?*

1:1 CeremonyGroup Ceremony3-Day Retreat3 Month Therapeutic Sessions
Would you like to be added to the community Telegram group?

YesNo
Physical and Mental Health Questionnaire
Please read the questions carefully and answer each one honestly based on your personal physical health: check YES or NO.

Cardiovascular Issues / Diseases*

	Yes	No
Heart Attack
Angina
Irregular Heart Beat or Arrhythmia
Deep Vein Thrombosis (DVT)
Blood Clots
Significant High or Low Blood Pressure

Blood Borne*

Respiratory Issues*

Neurological Health*

	Yes	No
Stroke
Transient Ischemic Attack (TIA or mini-stroke)
Aneurism
Epilepsy
Seizures
Recent Head Injuries
Concussions or Bleeding Brain Lesions
Anything else affecting the brain, nerves, or spine?

Mental Health *Relevant to Personal and Family**

	Yes	No
Schizophrenia
Psychosis
Manic- Depression
Bi-polar Disorder
Borderline Personality Disorder
Dissociative Identity Disorder
History of Suicide
Obsessive Compulsive Disorder
PTSD or CPTSD
General Anxiety
General Depression

Psychiatric Medications*

	Yes	No
(SSRI's) Selective Serototin Reuptake Inhibitors
(NDRI's) Norepinephirine Dopamine Reuptake Inhibitors
Tricyclics
(MAOI's) Mono-amine axidase Inhibitors

Please list any medications (Prescribed, Over-The-Counter, Vitamins, and Herbal Supplements)
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*

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Date

MoisJourAnnée
Thank you for completing this health screening truthfully and to the best of your abilities. Please ensure your phone number is accurate on this form and we will reach out to you directly via email with a few options to meet for our discovery call. We look forward to connecting with you.
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