Temple of Spirit Alchemy Intake Form

Temple of Spirit Alchemy Participant Intake Form
Confidential intake for new and returning participants in sacred healing ceremonies. Your responses help us ensure your safety and a meaningful experience.
Participant Information
Legal Name

First NameLast Name
Preferred Name
Email Address
example@example.com
Would you like to join our mailing list?
Mobile Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referral & Social
How did you hear about Temple of Spirit Alchemy?
Instagram handle/name
First and Last name of person that referred you

First NameLast Name
Experience
Have you ever attended a Bufo ceremony before?
How many times have you attended a Bufo ceremony?
Have you ever attended a Bufo ceremony with Temple of Spirit Alchemy and/or Ayako DeRuby?
Please provide date and City, State in which you attended a Bufo ceremony with Temple of Spirit Alchemy and/or Ayako DeRuby
Booking
Are you interested in a private session or group ceremony?
What date are you interested in booking?

MonthDayYear
Date
Personal Intentions
Please briefly state your reasons for seeking to attend a sacred healing ceremony with Temple of.
What are your current life challenges?
Are there any trauma triggers that you would like us to be aware of?
Please explain trauma triggers that you would like us to be aware of
What would you like to gain from this experience?
What is your occupation?
What are your hobbies/interests?
Who are the most important people in your support network
Is there any area where your support network is lacking?
Do you currently have a meditation or personal practice that supports your inner work outside of plant medicine?
If yes, please share: The nature of your practice (meditation, breathwork, yoga, prayer, etc.), How long you have been in this practice, The consistency or rhythm of your practice, How this practice supports you in your life
If you do not currently have a personal practice, are you open to participating in our Mind Alchemy Meditation Program as part of your preparation and integration? (This is a self-paced program and is offered at no cost.)
Certain medications may interact with altered states of consciousness. All disclosures are confidential and reviewed to support your safety.
Should be Empty:

Temple of Spirit Alchemy Participant Intake Form

Participant Information

Referral & Social

Experience

Booking

Personal Intentions