Consultation Intake Form
The information collected will support Ladybug in providing clear and aligned support during your free 20-minute consultation.
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What type of consultation are you interested in?
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1:1 Inner Healing / Shadow Integration Support
1:1 Microdosing Support
1:1 Pre/Post-Ceremony Support
On-Call Ceremony Support
Ceremony Consultation*
*If Ceremony Consultation is selected, it will be a 20-min alignment call; Full ceremony consultation is a paid service.
How did you hear about Haux Gatherings?
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Referral
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Basic Info / Demographics
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Phone Number
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Date of Birth
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Medical & Mental Health Disclosures
Height & Weight
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.
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, macrodosing experiences, etc.)
In general, how do you feel about your mental health at this time?
Consultation-Specific Questions
What brings you to this point in your journey where you are wanting to take this step?
Have you ever done this type of work before? What has your experience been?
What are you hoping to gain or experience by taking this step? What about your experience of life would you like to shift?
What are you looking for in a practitioner?
What are you NOT wanting in a practitioner?
What else would you like me to know before we schedule our call, so that we can use our time most efficiently?
What days/times are you most regularly available for a 20-minute call? And would you prefer phone or zoom?
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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