Ceremonial Intake Form
Please answer all questions as honestly and completely as possible in order for Haux Gatherings to provide the most helpful support for you on your healing journey.
Basic Info
Date
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Month
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Day
Year
Date
Preferred Name
First Name
Last Name
Email
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Phone Number
Please enter a valid phone number.
Ceremony Date
Please Select
Private Ceremony
May 25 The RESET Niños Santos Community Day Ceremony
June 7-8 Niños Santos Overnight, Tucson, AZ
June 15-16 Niños Santos Overnight, San Diego, CA
June 29-30 Grandmother Overnight, Pasadena, CA
July 13-14 Niños Santos Overnight, San Diego
July 19-21 Grandmother Weekend, Joshua Tree
Demographics
Pronouns
Date of Birth
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Month
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Day
Year
Date
Age
Medical & Mental Health Disclosures
Medical & Mental Health Disclosures
Please be as fully honest in this section as you can be, in order to support Haux Gatherings in providing the most aligned consultation services.
Height
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Weight
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Dietary Habits
I eat everything
Pescaterian
Vegetarian
Vegan
Gluten-Free
Nut Allergies
Other
Please list any prescription medications you are currently taking or have taken in the last six months, with dosage.
Please list any OTC medications or supplements you are currently taking, including frequency and dosage
Please disclose any mental health diagnoses you have received, whether you agree with the diagnosis or not. (We do not take this info as fact; it is helpful for identifying observed symptoms that could be addressed or come up in ceremony.)
Have you ever attempted suicide? Or been concerned or convinced that you might attempt suicide? If yes, how long ago? How do you relate to this experience today?
Are you currently or have you ever felt or experienced chemical or psychological addiction to any substances or behaviors? If yes, how do you relate to this experience today?
How often do you consume mind-altering substances (ex. alcohol, cannabis, microdosing protocols, macro-dosing experiences, etc.)
In general, how do you feel about your mental health at this time?
Ceremonial Information
Ceremonial Information
Your responses here will support Haux Gatherings in creating a container for your healing that will be most supportive and aligned for your current process.
(For 1:1 ceremony inquiry) What medicine(s) are you considering for your next ceremony?
Psilocybin
Cannabis
Ayahuasca
MDMA
5MeO / Bufo
Please share a bit about any past experience with entheogenic substances that you think may be helpful for me to know.
Have you ever had an experience that was guided by a professional? If yes, what was that like for you? If no, what brings you to this form of support?
What calls you to medicine work at this time? What calls you to this specific type of ceremony (1:1; group; deep-dive; lighter, etc.)
What is your intention for this next experience? What are you hoping to gain or shift through this experience?
Please describe your connection to spirituality and/or religion. What are your practices, aversions, etc?
Do you have a meditation or mindfulness practice, whether formal or informal?
Please share anything else you would like for me to know before we schedule a phone call to discuss alignment.
Waiver & Release of Liability
Waiver & Release of Liability
Submitting this form does not guarantee that Haux Gatherings or any individuals or entities connected with Haux Gatherings will perform any services. If alignment is mutual and services are rendered, you agree to hold harmless Haux Gatherings and all collaborative individuals and entities for any physical or psychological difficulty and/or damage. You acknowledge that Haux Gatherings is not a licensed medical or mental health entity, and agree to consult with licensed practitioners prior to engaging in any experiences with Haux Gatherings. Haux Gatherings will NEVER recommend coming off of or altering any prescribed medications, as this can result in significant psychological and/or physical side effects.
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