Cosmic Seed 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
Name*

First NameLast Name
Alternate, preferred, or nickname?
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Place of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Biological Sex*

FemaleMaleOther (please explain)
Gender Identity (How you prefer to be addressed / known, if applicable)
How did you hear about this?*
It's very helpful for us for security reasons to know who (specifically, by name or site) referred you to us.
Would you like to join our contact list?*

YesNo
What payment option would you like to choose?*

Extended Payment Plan - $355/month for 12 monthsMost Popular Plan - $422/month for 10 monthsPay in Full w/ Klarna - various month to month options - Bonuses IncludedOne Time Payment - Pay in Full - Bonuses Included
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.*

Marijuana / Cannabis / "Weed"TobaccoRapé / HapéPsilocybin / MushroomsLSD / "Acid"Wachuma / San PedroPeyoteMescalineAyahuascaIboga / IbogaineSalviaKamboKetamineDMT / NN-DMTBufo / 5-Meo-DMTMorning Glory / OloliuquiSonangaUremaKannaAmphetamine / Adderall / "Speed"MDMA / "Sally" / "Sass"2C-B / "Nexus"None of the AboveOther (please explain)
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.*

MeditationYogaDarknessNatureDance / MovementSexTantraBreathworkSpiritual Practice (any type)None of the AboveEmbodimentOther (please explain)
Please let us know about any particularly profound or important experiences that you have had in an altered or expanded state of consciousness, that are applicable to how you approach journey work at this point in your life.*
Have you ever had a challenging, problematic or unpleasant experience with psychedelics or with expanded states of awareness?*

YesNoNot Sure
If Yes above, please briefly describe the experience and what impact it had on you.
Mental Health History
Do you now or have you ever had a history of diagnosed psychiatric or psychological conditions?*

YesNoNot Sure
Have you ever been diagnosed with or treated for:*

Bipolar disorderAnxietySuicidePost-traumatic stressDepressionAngerSchizophreniaAlcohol abuseNoneOther (please explain)
If Yes above, please explain in detail including whether you have had a medical diagnosis, self-diagnosed, suspected, or suggested condition(s), what those conditions were, if they are past or current, and if/how they were treated. Some examples could include depression, anxiety, addiction, phobia, PTSD, or severe trauma.
Please check all of the following that apply to you. Do you currently have / see:*

CounselorTherapistCoachSupport Group12-Step ProgramSpiritual MentorNone of the AboveOther (please explain)
Have you ever experienced violence, abuse, or severe trauma? Do you have a history of being abused emotionally, sexually, physically or by neglect?*

YesNoNot Sure
If Yes above, and if you feel comfortable sharing, please briefly explain. Also, please mention if these experiences have a pattern of "coming up" for you during altered or enhanced states of awareness.
Any currently or do you have a history of any of the following?*

Depressed MoodRacing ThoughtsExcessive WorryUnable to enjoy activitiesViolent behaviorImpulsivityAnxiety attacksSleep pattern disturbanceChange in appetiteIncrease risky behaviorAvoidanceLoss of interestIncreased libidoDecreased libidoSuspiciousnessExcessive GuiltExcessive EnergyDecrease in EnergyIncreased irritabilityFatigueCrying spellsNone / Other (please explain)
Have you ever had feelings or thoughts that you didn't want to live?*

YesNo
If yes, When was the last time you had thoughts of dying?
Do you currently feel that you don't want to live?*

YesNo
If you have currently have thoughts that you don't want to live, How often do you have these thoughts?
Has anyone in your family been diagnosed with or treated for:*

Bipolar disorderAnxietySuicidePost-traumatic stressDepressionAngerSchizophreniaAlcohol abuseNone of the AboveOther (please explain)
Substance Use History
Are you currently taking any medications or using any substances? Please check all that apply:*

PharmaceuticalsPlant-Based MedicinesAlocholTobaccoCaffeineVitamins / Supplements / NootropicsNone of the AboveOther (please explain)
For anything you checked above, please list out all substances you consume on at least a monthly basis, and describe how often you take them, if you take them daily, weekly, or monthly. Include items such as Cannabis, Kratom, and Cacao, and all pharmaceuticals including anti-depressants, anti-anxiety medications, and even "over-the-counter" medications if you take them regularly. If you are taking daily supplements or a nootropic "stack", please specify.
What is your typical sensitivity to psychedelics?*

Highly Sensitive - I need much less than the average personSensitive - I need somewhat less than the average personAbout Average - I seem to do well with standard dosingTolerant - I need somewhat more than the average personHighly Tolerant - I need much more than the average personOther (please explain)
What is your typical sensitivity to other substances (stimulants, sedatives, pain killers, etc.)*

Highly Sensitive - I need much less than the average personSensitive - I need somewhat less than the average personAbout Average - I seem to do well with standard dosingTolerant - I need somewhat more than the average personHighly Tolerant - I need much more than the average personOther (please explain)
Medical History
Considering your age, how would you describe your overall health?*

ExcellentGoodFairPoorOther (please explain)
Do you have any currently known medical conditions?*

YesNoNot Sure
If Yes or Not Sure above, please briefly describe any current medical conditions, or explain why you're not sure.
Check the conditions that apply to you or any member of your immediate relatives:*

AsthmaCancerCardiac diseaseHypertensionDiabetesPsychiatric disorderEpilepsyOther (please explain)
Are you pregnant?*

YesNoNot Sure
Do you have any history of heart-related medical issues, or high / low blood pressure?*

YesNoNot Sure
Is there any previous hospitalization?

NoYes, please explain
If Yes above, please briefly explain.
Have you ever had an adverse reaction to any medications?*

YesNoNot Sure
If Yes above, please briefly explain.
Do you have any special diet or dietary restrictions?*

NoneVeganVegetarianPaleoKetoHalalDairy FreeGluten FreeOther (please explain)
Do you have any allergies, food allergy, chemical sensitivity, or other special needs?*
Intentions
What are your intentions in seeking this experience? What are you hoping to gain, and what are you expecting?*
Is there anything not already mentioned that you would like for us to know about you in order to best support you?*
Should be Empty: