SGC Health and Safety Questionnaire

Health and Safety Questionnaire
You should have already signed our Release of Liability Waiver, if not please do so now.

Please take time to reflect on your answers to the questions below. Please be as forthright as possible as your answers will help ensure you have a safe and positive Practice.

Your responses are only accessible to Sacred Garden Community Facilitators and will only be read when it is directly relevant to facilitation. If you have any concerns, please feel free to email intake@sacredgarden.life before engaging the questionnaire.

After completing this form and e-signing the Waiver, the next step is to complete an intake interview. Visit https://www.sacredgarden.life/intake or contact intake@sacredgarden.life to schedule your intake.
Full Name*

First NameLast Name
Preferred Name
What would you like to be called?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
example@example.com
Phone Number*
What are your preferred pronouns?

She/HerHe/HimThey/ThemOther
Emergency Contact Name*

EC First NameEC Last Name
Emergency Contact Phone Number*
Is this emergency contact person aware of your SGC practice and can we identify ourselves if we need to call them?*

YesNo
Sacrament Status
Sacrament(s) screened for:

XangaMDMAPsilo5-MeO-DMT
Intake Note
Provisional Concerns Note
Facilitator Notes
Facilitators, please share any information you think is important for other facilitators to know about this person.
Health Screening Questions

Before engaging in any form of deep meditation practice, please discuss any and all medications you are taking, and any illness with your facilitator.
When was your last physical?*

MonthDayYear
Date
Birthday*

DayMonthYear
Date
How tall are you?*
How much do you currently weigh?*
What is your age?
Have you been medically diagnosed, have you experienced, or do you experience:*

Pre-existing cardio-vascular disease, stroke or aneurysmSignificant high blood-pressureRespiratory disordersSeizures or other neurological conditionsSignificant allergies (food, environmental, drug - anything requiring medical intervention if exposed)Currently Pregnant or BreastfeedingDiabetesRecent major surgery (requiring general anesthetic) or significant injurySevere Liver or Kidney DiseaseNone of the aboveOther
Are you affected by any of the following mental health concerns*

DepressionBipolar disorder (also known as manic depression)AnxietyPost Traumatic Stress disorder (PTSD)Obsessive Compulsive disorder (OCD)Schizophrenia or Schizoaffective disorderSocial Anxiety disorderHospitalization within the past year for a mental health challengeOther Anxiety disorderNone of the aboveOther
Do you ever take any prescription or over-the-counter medications?*

YesNo
Are you taking currently, or have you ever taken any prescribed psychiatric medication intended to shift your mood and or stabilize emotional distress? (Some major categories are described below)*

Antidepressants: SSRIs, SNRIs, Tricyclics. Commonly prescribed for depression, anxiety, PTSD. Common medications include Prozac, Zoloft, Paxil, Lexapro, Effexor, Wellbutrin (also Zyban), Cymbalta, Parnate, Elavil.MAOI (monoamine oxidase inhibitors) Common names include Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)Anti-Anxiety Agents: Benzodiazepines. Commonly prescribed for anxiety and panic attacks. Common medications include Valium, Xanax, Klonopin, Ativan.Stimulants: Commonly prescribed for ADHD. Common medications include Ritalin, Adderal, Vyvanse, Dexadrine, Concerta.Antipsychotics: Commonly prescribed for schizophrenia, sometimes prescribed for significant anxiety, depression, PTSD, bipolar disorder, sleep difficulties. Common medications include Haldol, Zyprexa, Risperdal, Seroquel, Geodon, Abilify.Mood Stabilizers: Commonly prescribed for bipolar disorder (manic depression). Sometimes prescribed for depression, epilepsy. Common medications include Lithium, Depakote, Lamictal.None of the aboveOther
Please describe your history and current engagement with the following substances.*

Alcohol - dependence patterns, binge pattern Antidepressants: SSRIs, SNRIs, Tricyclics. Commonly prescribed for depression, anxiety, PTSD. Common medications include Prozac, Zoloft, Paxil, Lexapro, Effexor, Wellbutrin (also Zyban), Cymbalta, Parnate, Elavil.Opiate - MAOI (monoamine oxidase inhibitors) Common names include Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)XXX Anti-Anxiety Agents: Benzodiazepines. Commonly prescribed for anxiety and panic attacks. Common medications include Valium, Xanax, Klonopin, Ativan.Stimulants - Methamphetamine, Commonly prescribed for ADHD. Common medications include Ritalin, Adderal, Vyvanse, Dexadrine, Concerta.Ketamine - Commonly prescribed for schizophrenia, sometimes prescribed for significant anxiety, depression, PTSD, bipolar disorder, sleep difficulties. Common medications include Haldol, Zyprexa, Risperdal, Seroquel, Geodon, Abilify.: Commonly prescribed for bipolar disorder (manic depression). Sometimes prescribed for depression, epilepsy. Common medications include Lithium, Depakote, Lamictal.None of the aboveOther
Absolute Contraindications (for certain liturgies) - Are you currently taking any of the following medications? (If so, please be sure to discuss the implications during your intake interview)*

MAOI's (monoamine oxidase inhibitors) Common names include Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)HIV/AIDS meds such as ritonavir or cobicistat or efavirenzArrhythmia medications: Amiodarone, Diltiazem, Sotalol, Quinidine, Procainamide, Dofetilide, Ibutilide, Digoxin.Bupropion (Wellbutrin)Carbamazepine, oxcarbazepine, or valproic acidFluconazole (Diflucan)LithiumNone of the above
Cautionary Medications (for certain liturgies these drugs can shorten time of onset, increase peak blood level and/or create unpredictable changes to efficacy at usual amounts) - Are you currently taking any of the following medications? (If so, please be sure to discuss the implications during your intake interview)*

Cimetidine (Tagamet)Fluoxetine (Prozac)Paroxetine (Paxil)Stimulants: Commonly prescribed for ADHD. Common medications include Ritalin, Adderal, Vyvanse, Dexadrine, Concerta.First Generation antihistamines (Diphenhydramine, Chlorpheniramine, Promethazine (Phenergan), Prochlorperazine (Compazine), Meclizine, Hydroxyzine)NSAID DiclofenacFluconazole (antifungal)None of the above
Please list all prescription and over the counters medications you currently consume regularly, include the name, the reason, the dose and frequency.
This information will be kept under [Pastoral] confidentiality and may be shared with ordained facilitators and SGC's medical support team.
Please list all supplements (vitamins, nootropics, herbs, etc) and other substances/drugs you currently consume regularly, include the name, the reason, and frequency.
This information will be kept under [Pastoral] confidentiality and may be shared with ordained facilitators and SGC's medical support team.
Experience

We would like to know a bit your experience with the Sacraments of our church, as well as any other entheogens you consider to be a Sacrament
Do you have experience with any Sacraments of our Church or any other entheogens?

YesNoI'm not sure what you mean by "sacraments" or "entheogens"
If so, when was your first experience? What Sacrament(s) or material(s) have you had experience with? And in what context (group ceremonies, festivals, guided solo journeys, journeys with partners, etc)?
If you have had experience with entheogens before, what sacraments?
If you have had experience with entheogens before, roughly how long ago was your most recent experience?

MonthDayYear
Date
If you have had experience with entheogens before, how has/have the experience(s) been for you in general? (and yes, we understand it is usually different each time, so feel free to note the range)
What is an entheogen?

Come to SGC's Sunday Services at 11am PT on this Zoom link: https://us02web.zoom.us/j/8468635546 and learn more! Or start your own research here: https://www.google.com/search?client=safari&rls=en&q=entheogen+meaning
Personal Questions

Although some emotional concerns may be benefited by participation, considerations in participating must be made on a case-by-case basis. All mental health concerns should be clearly and openly communicated with the prospective Facilitator as part of the health screening process. Please note that we are not medical or mental health practitioners and this is not medical or mental health care. Your full and open participation in the consideration process will support you in having a more positive experience. And your full honesty will cultivate a rapport full of trust, care, and respect with your facilitator. While it may not be appropriate for every Practitioner to engage with every sacrament, SGC will always work with you to find the most appropriate spiritual care.
What are your reasons for wanting to engage the sacraments of our church?*
Please describe any traumatic events that have impacted your life that you feel comfortable with sharing. (If you don't feel comfortable sharing via this form - but do have trauma that feels relevant - please indicate that you would prefer to be asked about this in person.)
Are you currently facing any strong or persistent fears in your life?*
Are you currently experiencing any unusual stress, overwhelm, or life challenges? *
Please describe.
What support systems, in terms of resources and relationships, do you have in place that can be of support after deep meditation?*
Examples may include: Family, friends, co-workers, other church, mosque, temple, therapists, spiritual teachers, etc.
Do you currently have a personal spiritual and/or self-care practice (like sitting meditation or other mindfulness practices; yoga, tai chi, or other embodiment practices)? If yes, please briefly describe them:*
Please briefly describe ways you have practiced and/or studied religious and/or spiritual paths. *
Teachers, level of participation, books read, etc.Teachers, level of participation, books read, etc.
Is there anything you would like to share about your identities (racial, gender, sexual, cultural, etc.) and/or any hopes or concerns you have related to how we can make Sacred Garden Community a more safe and welcoming space for you?
We recognize that sometimes people are drawn to this work because they are wrestling with existential issues. At the same part time of SGC's careful practice involves finding out more about your experience.*

Have you wished you were dead or wished you could go to sleep and not wake up in the past month?Have you had any thoughts about killing yourself in the past month?Have you attempted suicide within the last year?None of the above
Consent

For each sacrament practice we create a "container" that is held loving by our intentions and agreements. Different liturgies (with different sacraments) will have different intentions, and different agreements around welcomed behaviors. Some may require silence throughout the practice, while others will welcome sound and singing. One very significant dimension of these agreements is around touch, energy exchange, sensuality, and sexuality. All SGC sacrament practices are within a strictly Platonic container meaning non-sexual, non-romantic (your facilitator will explain more about what this means during your preparation.)
Do you agree to follow the guidance of your facilitator when it comes to upholding the agreements of the sacramental containers in which you practice with SGC? (ie. If the facilitator tells us this is a no touch ceremony I agree not to touch.)*

I agree and understand that if I do not uphold the agreements, the facilitator will call attention to my behaviors and may need to redirect meI do not understand the question well enough to agree to itI don't believe I can be held accountable for my behaviors while I am under the influence of certain sacraments
What are your preferences regarding touch (non-sexual)? When interacting with people that you don't have any prearranged consent around touch would you prefer:*

Green – You can touch me (non-sexually) without asking and I will let you know if I don’t like the way you are touching me.Yellow – You can offer me touch beyond what's needed to keep and other physically safe, and I will let you know if it’s ok.Red – Do not ever touch (or offer me touch) me unless its a matter of safety. If I want touch, I will initiate that conversation.Blue – Good question! I’m not entirely sure what my preferences around touch are, please talk to me about this.I don't understand enough about this question and the nature of the practices to answer in good faith, please talk to me about it moreConsent is more complex than a color, I'll discuss this with my facilitator
As noted above there may be times when a facilitator has to touch you as a means of keeping yourself and/or other practitioners safe from harm, regardless of your stated boundaries. If you become disruptive or unsafe in ceremony a facilitator may make the judgment call to use touch to keep you and others safe from harm. It is rare this happens, and in case it does... If you are not a "green" can you be explicit in how to deal with touching you for safety reasons? (ie, if possible, approach me from the front, not the side or behind, and if possible make eye contact with me, and narrate what you are about to do and why, like "I'm concerned you are going to fall and hurt yourself, so I'm going to move to your side and put my arm around you to keep you from falling)
Sometimes we have strong experiences that may overwhelm our ability to remember the behavioral agreements of the container and/or result in behavior that is disruptive to other practitioners' experiences. If this happens in ceremony a facilitator may make the judgment call to redirect you.
Rupture & Repair
Again, we want to remind you that consent is an ongoing conversation, it is not a static, once and done declaration. It is a dynamic process that you have agency to direct in each and every moment. It is your responsibility to make sure your preferences around touch are explicitly clear to your facilitator before every ceremony. And if anything ever does not feel right in the moment, we encourage you to use immediacy and address it in the moment.In the event that something you find offensive or in violation of your safety happens, that you were not able to address in the moment, please take note of SGC's Saftey Resources.
As mentioned before, this form does not allow you to go back and edit previous answers. If any additional info sprung to mind while answering later questions, after you submitted the answer to the original question, please make a note of it here.
Do you have any other questions, comments, and/or concerns you'd like to voice?
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Health and Safety Questionnaire

Health Screening Questions

Experience

What is an entheogen?

Personal Questions

Consent

Rupture & Repair