BUFO ALVARIUS CEREMONY HEALTH & WELLNESS SCREENING QUESTIONNAIRE

BUFO ALVARIUS CEREMONY HEALTH & WELLNESS SCREENING QUESTIONNAIRE
We thank you for your interest in Bufo Alvarius Ceremonies with Michael. Once this form has been completed you will receive an e-mail with a secure payment link to pay your chosen amount for your Bufo Ceremony / Ceremonies Package. Payment is due within a maximum of 24 hours from receiving the link to hold your space for the ceremony/ceremonies.

This form is held within the strictest confidence and is subject to Casa Galactica´s Privacy Policy. The purpose of this form is to ensure that we have a full understanding of your present-day health and wellness status, allowing us to ensure your safety and the the facilitator for your Bufo Alvarius Ceremonies.

We will comprehensively review your completed questionnaire and assess your suitability to smoke Bufo Alvarius without contraindications. We will also discuss your completed form with you during your online, private Pre-Retreat Preparation Session via Zoom video-call, confirming at that time if we are able to safely accept you for Bufo Alvarius Ceremonies.

ACCORDINGLY, IF YOU ARE TRAVELLING TO PERU FOR CEREMONY, PLEASE WAIT TO BOOK YOUR FLIGHTS UNTIL AFTER YOU HAVE COMPLETED YOUR PRE-CEREMONY PREPARATION SESSION AND RECEIVED ACCEPTANCE FOR CEREMONY/CEREMONIES. IF FOR ANY REASON YOU ARE NOT ACCEPTED FOR THE CEREMONY, YOUR PAYMENT WILL BE 100% REFUNDED.

Please complete this form by answering all of the questions as honestly and as thoroughly as possible so that we can uphold the highest standards of safety, care, and integrity within all of our healing work with you. Omitting information can result in your own physical harm, psychological impairment, and even death. Your completed form also aids us in helping you get the most out of your healing experience with us.

DO NOT CLICK BACK OR REFRESH YOUR BROWSER AT ANY POINT THROUGHOUT THE BOOKING PROCESS AS INPUTTED DATA MAY BE BE LOST. We recommend writing and saving your answers into a word document to avoid losing them. When you are ready, copy and paste them into this booking form.

CASA GALACTICA RECOMMENDS THAT YOU PURCHASE TRAVEL INSURANCE TO COVER ANY AND ALL EVENTUALITIES. CASA GALACTICA IS NOT LIABLE FOR ANY EXPENSES RELATED TO THE CANCELLATION OF YOUR TRIP/CEREMONY.

If you have any further questions, please get in contact with us via our Contact Us page. We are also available for a Zoom, WhatsApp, or Signal phone/video-call upon request, and you may send us a message via Whatsapp or Signal, +51 943 364 714, or via email, contact@casagalactica.com, to schedule it.

In Service,
Michael Thornhill
Co-founder of Casa Galactica
www.casagalactica.com
Full Name

First NameLast Name
Contact Number

Country CodePhone Number
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you find out about our Bufo Ceremonies?*

Casa Galactica WebsiteCasa Galactica NewsletterA ReferralPodcastRetreat GuruTrip AdvisorInternet SearchOther
EMERGENCY CONTACT DETAILS
Who is your emergency contact person?*

First NameLast Name
What is your emergency contact person's relation to you?*
Emergency Contact Person Cell Phone Number

Country CodePhone Number
MEDICINAL PLANTS /ENTHEOGEN EXPERIENCE
Have you ever participated in an Bufo Alvarius ceremony?*

yesno
If Yes, please describe your experience(s) including how many times, when, where, if you had any adverse reactions, and any specific traditions you've experienced ceremony within.
Have you ever participated in an Ayahuasca ceremony?*

yesno
If Yes, please describe your experience(s) including how many times, when, where, if you had any adverse reactions, and any specific traditions you've experienced ceremony within.
Have you ingested or worked with any other entheogens or medicinal plants?*

yesno
If Yes, please describe your experience(s) including how many times, when, where, if you had any adverse reactions, and any specific traditions you've experienced ceremony within.
PHYSICAL HEALTH HISTORY
What is your age?*
Are you pregnant, or could you be pregnant?*

YesNoThis question does not apply to me
Please check any physical health conditions that you are currently experiencing or have previously experienced*

Low blood pressureHigh blood pressureHeart surgeryCirculatory problemsIrregular heartbeat (dysrhythmia)DiabetesMeningitisMigraneEpilepsySeizuresFaintingHyperthyroidismHypothyroidismCancer or tumorHIV/AIDSUlcerObesityPhysical disabilityChest painAsthmaAneurysmChronic painFibromyalgiaArthritisStrokeHead injuryInfectious diseaseNeurological diseaseGynaecological diseaseLung ProblemsBreathing DifficultyCardiovascular ProblemsOther (please specify below)NONE OF THE ABOVE
If you checked "Other" above, please describe.
Please share any additional relevant details about the specific physical health conditions you checked above.
In your own words, how would you describe your current state of physical health? *
Have you ever undergone any form of surgery?*

yesno
If Yes, please provide details of the surgery, the related physical condition, the date of surgery, and any limitations you have as a result of the surgery.
PSYCHOLOGICAL HEALTH HISTORY

In order to ensure your safety it is important that we have full knowledge of any psychological health conditions that you are currently experiencing or have experienced in the past. Please be as honest as possible when answering the following questions. Bufo Alvarius can be used to assist many of the following psychological conditions when approached in the right way. Your safety is our highest priority, and we will use this information in strict confidence to determine if Bufo Alvarius can benefit for you right now. If we determine they are not, we will recommend other treatment programs that can be more beneficial for you on your healing journey.
Please check any psychological health conditions that you are currently experiencing or have previously experienced*

SchizophreniaParanoiaPanic attacksAttention deficit disorderAttention deficit hyperactive disorderObsessive compulsive disorderSuicidal ideation (thoughts about suicide or suicide attempts)Post-traumatic stress disorder (PTSD)PsychosisBipolar disorderDissociationDissociative identity disorderEating disorderChronic anxietyAutismAsperger's syndromeBorderline personality disorderDepersonalization disorderOther (please specify below)NONE OF THE ABOVE
If you checked "Other" above, please describe.
Please share any additional relevant details about the psychological health conditions you checked above.
Do you have a family history of any of the above psychological health conditions listed above, or any others that you are aware of? *

yesno
If Yes, please specify which family member(s), which psychological health condition(s), and describe their current state of psychological health.
In your own words, how would you describe your current state of psychological health? *
SPIRITUAL HEALTH HISTORY

"Spiritual health" refers to the wellness of that core dimension of you - your innermost self - that provides you with a profound sense of who you are, where you came from, where you're going, and how you might get there. You may not think much about spiritual health or well-being and what role it plays in your life, but its significance is stronger than you may believe. Spiritual health means different things to different people. Your answers to the questions below will help us to better understand your unique set of spiritual "tools" and will enable us to support you through any personal challenges that may arise for you.
What gives your life meaning and purpose? *
Describe a time in your life when you felt all was right with the world. *
Describe a time in your life when you felt a sense of deep meaning or when you experienced a sense of awe. *
Describe a time in your life when you survived a loss or difficult experience and how you did so. *
Please check any spiritual health conditions which you are currently experiencing or have previously experienced. *

EmptinessAnxiety/WorryLoss of meaningAimlessnessLonelinessDepressionSelf-judgmentSelf-condemnationSeparationAlonenessUnloved-nessApathySelf-condemnationFearUnworthinessOther (please specify below)NONE OF THE ABOVE
If you checked “Other” above, please describe.
Please share any additional relevant details about the spiritual health conditions you checked above.
What are your sources of strength, hope, comfort, and peace in times of difficulty? *

Prayer/MeditationReligionHigher Power/GodReadingNatureSelf-lovePets/AnimalsSpeaking with othersCounseling/TherapyFriendshipWriting/JournalingPlayGardeningRecovery groupsYogaCreativity/Music/ArtAcceptanceExerciseForgivenessMassageGratitudeCompassionOther (please specify below)NONE OF THE ABOVE
If you checked “Other” above, please describe.
Please share any additional relevant details about the sources of strength you checked above.
Do you belong to or adhere to a spiritual, religious, or 12-step recovery community? *

yesno
If Yes, what specific spiritual, religious, or recovery practices or restrictions should we know about to best support you, if any?
Do you consider yourself intuitive, empathic, sensitive to energies, or emotionally receptive? *

yesno
If Yes, please tell us about this experience and how it expresses itself in your life.
In your own words, how would you describe your current state of spiritual health? *
ABUSE & TRAUMA HISTORY

It is common for experiences of trauma and/or abuse to arise in a Bufo Alvarius Ceremony for the purposes of personal healing. Although powerfully transformative, these intense experiences in ceremony can be challenging or difficult to integrate at times. Your safety, health, and well-being is our utmost priority before, during, and after ceremony. It is beneficial for us to know any experiences of trauma or abuse that you are consciously aware of in order to best support you when or if it should arise.
Please check any abusive conditions that you are currently experiencing or have previously experienced. *

PhysicalSexualVerbal/EmotionalMental/PsychologicalReligious/SpiritualRacismEnslavementHomophobiaStalkingHate crimeRitual/CultFinancial/EconomicCultural/IdentityNeglect/AbandonmentHarassment/BullyingOther (please specify below)NONE OF THE ABOVE
If you checked "Other" above, please describe.
Please share any additional relevant details about the abusive conditions you checked above.
Please check any traumatic events that you are currently experiencing or have previously experienced. *

Death of a loved one or petDivorceRape/MolestationAttack by dog or other animalPrison stayPhysical pain or injurySerious illnessExtended hospital stayOperation/SurgeryNatural disasterWarTerrorismMoving to a new locationSuicide attemptParental abandonmentNear-death experienceWitness to a deathWitness to a bad accidentHeld at gunpointMuggingBurglaryOther (please specify below)NONE OF THE ABOVE
If you checked "Other" above, please describe.
Please share any additional relevant details about the traumatic events you checked above that you feel may be helpful for us in supporting you during your ceremony
ALCOHOL, DRUGS & ADDICTION HISTORY

Bufo Alavarius has the potential to be used as a treatment for dependence and addiction. Your answers to the questions below will allow us to better assist your healing during your time with us.
Do you feel, or have you ever felt, that you have a drinking problem? *

yesno
Are you a self-identified alcoholic, have you ever been diagnosed with alcoholism, or have you ever been treated for alcoholism?*

yesno
If Yes, please provide additional information about your experience including the date(s) or time span of your alcoholism and whether you have undergone any therapy, treatment, or rehabilitation to heal.
Do you feel, or have you ever felt, that you have a drug problem?*

yesno
Are you a self-identified drug addict, have you ever been diagnosed with a drug addiction, or have you ever been treated for drug addiction? **

yesno
If Yes, please provide additional information about your experience including the date(s) or time span of your addiction, type(s) of drugs, and whether you have undergone any therapy, treatment, or rehabilitation to heal.
Type a question*

GamblingShoppingWorkPornographySelf-harmingSexLove & RelationshipsFoodEating disorderPrescription medicationsGamingOther (please specify below)NONE OF THE ABOVE
If you checked "Other" above, please describe.
Please share any additional relevant details about the addiction(s) you checked above.
MEDICATION & ALLERGIES

In order to ensure your safety it is important that we have full knowledge of any medication that you are currently taking or have recently taken within the past 6 months. Please be as honest as possible when answering the following questions. Bufo Alvarius is contraindicated with certain prescription medicines and supplements. Your safety is our highest priority, and we will use this information in strict confidence to determine if Bufo Alvarius is of optimum benefit for you right now. If we determine it not, we will recommend other treatment programs that can be more beneficial for you on your healing journey.
Are you currently taking, or have you recently taken, prescription medication(s) within the past 6 months? *

yesno
If Yes, please specify which prescription medication(s).
Are you currently taking, or have you recently taken antidepressant medication(s) within the past 6 months? *

yesno
If Yes, please specify which antidepressant medication(s).
Are you currently taking, or have you recently taken, natural supplement(s), herbal medicine(s), or vitamin(s) within the past 6 months? *

yesno
If Yes, please specify which natural supplement(s), herbal medicine(s), and/or vitamin(s).
Are you allergic to any medication(s)? *

yesno
If Yes, please specify which medication(s).
Do you have any severe or potentially life-threatening allergies that would require the use of an EpiPen? *

yesno
If Yes, please specify.
INTENTION

If you have not done so already, it is important to spend some time meditating (or thinking) about your intention for your upcoming ceremony. Please write this down and share it with us here so that we can assist you in obtaining the most out of your upcoming ceremony.
What is your personal intention for this ceremony, and what are you hoping to experience? *
ADDITIONAL INFORMATION FOR CEREMONY
What additional information concerning your physical, psychological, or spiritual health history would you like to share with us?
Please describe your current living/work situation, including if you are studying or working, your profession, and your home environment that you will be returning to after your ceremony. This information helps us prepare you for post-ceremony integration *
In this questionnaire I have disclosed all prescribed medications, plant medicines, supplements, street/recreational drugs, medical conditions, and medical treatments or therapy that I am currently taking, experiencing, or undergoing. *

yes
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BUFO ALVARIUS CEREMONY HEALTH & WELLNESS SCREENING QUESTIONNAIRE

EMERGENCY CONTACT DETAILS

MEDICINAL PLANTS /ENTHEOGEN EXPERIENCE

PHYSICAL HEALTH HISTORY

PSYCHOLOGICAL HEALTH HISTORY

SPIRITUAL HEALTH HISTORY

ABUSE & TRAUMA HISTORY

ALCOHOL, DRUGS & ADDICTION HISTORY

MEDICATION & ALLERGIES

INTENTION

ADDITIONAL INFORMATION FOR CEREMONY