Full Name
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First Name
Last Name
E-mail
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Confirmation Email
example@example.com
Phone Number
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Area Code/Country Code
Phone Number
City & Country Where You Reside
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How Did You Hear About Us
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A Friend/Family Member
Internet Search
Social Media
Youtube
Podcast
Article
Other
Do you take any pharmaceutical medications or street drugs?
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yes
no
If "Yes" then please list what types
Length of time using AND quantity
Level of perceived trauma (scale of 1-10)
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How much work have you already done on these traumas? (scale of 1-10)
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Do you have a heart or liver condition that you are aware of?
*
yes
no
Monthly Income (please answer honestly)
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$0-$2000
$2000-$3000
$3000-$4000
Please tell describe IN DETAIL your financial situation and why you should be considered for this partial scholarship. Please understand that these are limited and they need to be allocated to those in the most need
*
What is your previous personal growth and plant medicine experience
*
Please tell us why this sacred medicine is calling you
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