• Intake Application

    Intake Application

    We appreciate you taking the time to provide this information so that we can provide the best experience possible for all our guests.

  • Please know that we keep all the information provided in this form in the strictest confidence and we will not share it with ANYONE outside the Sacred Explorer Team. The data submitted through this site is encrypted, and only the Sacred Explorer Administrator holds the private encryption keys in a secure location. Your privacy is of supreme importance to us, and this information will only be used to help us create a safe and positive environment for all our guests.

  • Basic Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Biological Sex*
  • Would you like to join our contact list?*
  • What payment option would you like to choose?*

  • EXPERIENCE WITH
    EXPANDED STATES OF
    CONSCIOUSNESS

  • Please check any of the following substances that you have experience with one or more times in your life.*
  • Please check any of the following activities that have led to what you would consider an expanded or altered state of consciousness, in the absence of substances.*
  • Have you ever had a challenging, problematic or unpleasant experience with psychedelics or with expanded states of awareness?*

  • Mental Health History

  • Do you now or have you ever had a history of diagnosed psychiatric or psychological conditions?*
  • Have you ever been diagnosed with or treated for:*
  • Please check all of the following that apply to you. Do you currently have / see:*
  • Have you ever experienced violence, abuse, or severe trauma? Do you have a history of being abused emotionally, sexually, physically or by neglect?*
  • Any currently or do you have a history of any of the following?*
  • Have you ever had feelings or thoughts that you didn't want to live?*
  • Do you currently feel that you don't want to live?*
  • Has anyone in your family been diagnosed with or treated for:*

  • Substance Use History

  • Are you currently taking any medications or using any substances? Please check all that apply:*
  • What is your typical sensitivity to psychedelics?*
  • What is your typical sensitivity to other substances (stimulants, sedatives, pain killers, etc.)*

  • Medical History

  • Considering your age, how would you describe your overall health?*
  • Do you have any currently known medical conditions?*
  • Check the conditions that apply to you or any member of your immediate relatives:*
  • Are you pregnant?*
  • Do you have any history of heart-related medical issues, or high / low blood pressure?*
  • Have you ever had an adverse reaction to any medications?*
  • Do you have any special diet or dietary restrictions?*

  • Intentions

  • Should be Empty: