The Golden Channel Inquiry Form

THE GOLDEN CHANNEL - INQUIRY FORM
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you at least 21 years of age or older
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Profession
Linkedin Profile or other Professional/Career Page. If no career page, please include a link to social media page
Education
Date of Birth

MonthDayYear
Date
We offer HERO rates. Do you have any affiliation to military, law enforcement, government? If yes, thank you and please share how you serve
The questions below are required for your safety. Your responses are treated with strict confidentiality and are accessible only to Dr. Stefanie and authorized facilitators. See our Privacy Policy for full details on how this information is collected, stored, and retained: https://thesacredhouseofeden.com/privacy-policy
Please list any medical conditions:
Please list all medications and supplements you are currently taking. Include: name, dose frequency, how long you have been taking them (ex: Lipitor, 20 mg, 1xdaily, for 2 years. Vitamin C, 500mg 1xdaily, 5 years, etc.)
Do you have any personal or family history of the following: seizures, psychosis, mania, panic disorders, paranoia, suicidal ideation, or suicide attempts?
I have a personal history of (select all that apply)
What is your intention for joining The Golden Channel microdosing + coaching program?
Have you ever microdosed before?
Have you ever microdosed before?
If you have microdosed before, please tell us about your experience:
Which plant medicine properties most speak to you at this time?
Please share a bit about your current wellness practices and routine:
Please share a bit about your religious or spiritual beliefs & practices. If you do not have one, you can write N/A:
On a scale from 1-10, how committed are you to making your wellness a priority?
How did you learn about The Golden Channel?
If you have been referred to us, please tell us (by name) who referred you:
Anything else you feel is important for us to know:
Your signature here is attesting to the above information being correct and your agreement to the following terms: https://thesacredhouseofeden.com/golden-channel-terms
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The Golden Channel Deposit/Month 1 & 2
Your deposit will go toward your Golden Channel membership, covering your entire 1st & 2nd month. If for any reason, we determine that The Golden Channel is not a match for you, we will refund your deposit immediately.

$667.00

25-minute Private Consultation with Dr. Stefanie
We highly recommend you set up a 25-minute Private Consultation with Dr. Stefanie to discuss each of the 3 medicine options, to go over intentions. and to have an opportunity to ask any questions you may have. This will help ensure you select the best option for you and your 4-month protocol is off to the perfect start!

$149.00 Quantity

Total

$0.00
I have read and agree to the Privacy Policy, Participant Agreement, and Golden Channel Terms. I understand that the information I am providing, including medical and mental health history, is true and complete to the best of my knowledge: https://thesacredhouseofeden.com/privacy-policy https://thesacredhouseofeden.com/golden-channel-terms
Should be Empty:

THE GOLDEN CHANNEL - INQUIRY FORM