Sacred Sanctuary Intake Form

  • Sacred Sanctuary Intake Form

  • Please read the information on this page before getting started.

    The following form helps us understand a little bit more about you and how we can best ensure that you have a safe experience during our sacred ceremonies.

    You are required to complete this Intake Form before you will be eligible to participate in any of our sacred ceremonies.

    All of your responses are entirely confidential. Please read each question and answer carefully.

  • Acknowledgement

  • I acknowledge that I am choosing to participate in Ayahuasca ceremonies held by Sacred Sanctuary and its team. I agree to answer all the questions below honestly and that I must complete this form before being formally accepted as a participant.

    I understand and agree that this Intake Form allows for ministerial assessments about permitting use of the Sacraments based on my health conditions and publicly available medical information about our Sacrament and contraindications. Sacred Sanctuary’s ministerial assessment means it is performed without diagnosis or the use of medical or therapeutic services or determinations, even where developed based on available medical information about contraindications and non-medical criteria that create excessive risks. Our assessment does not constitute medical clearance of your fitness to engage in our ceremonies. You are encouraged to consult with a qualified medical and/or mental health professional to determine the full risks of your participation given your medical history. This Intake Form incorporates the disclosures and releases that will be separately provided to you in a document entitled “Participation Agreement, Release, Waiver and Indemnity Agreement.”

    Please respond to every section. If any section is not applicable, I may write “N/A.” If I have any questions or concerns, I will speak with an authorized representative of Sacred Sanctuary prior to submitting this completed Intake Form. I also agree to promptly update an authorized representative of Sacred Sanctuary if any information provided changes between the time this Intake Form is completed and any ceremonial sessions with Ayahuasca.

    I understand that based on the information provided in this form, I may be excluded from participation in the requested ceremony if Sacred Sanctuary and its team deem for any reason in their sole discretion that it may not be safe for me to participate in the selected ceremony.

     

  • Personal Information

    Please answer the following questions about yourself.
  • Today's Date*
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  • Format: (000) 000-0000.
  • Birth date*
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  • Select desired ceremony date:*
  • Accommodations - Our ceremonies offer shared accommodations. Please select all that apply.*
  • Format: (000) 000-0000.
  • Select, food preferences for chicken and eggs. Both are served during our retreats.*

  • Please upload a picture of your driver's license or government issued ID.

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  • Medical History

    Please answer the following questions regarding your medical history. Please acknowledge if you have in the past, or are currently, experiencing the following:
  • Have you been diagnosed in the past or currently with any of the following conditions?*
  • Are you currently pregnant, breastfeeding or trying to get pregnant?*

  • Mental Health and Drug Use

    Please answer the following questions regarding your mental health and drug use.
  • Do you suffer from any of the following mental conditions? Please select all that apply.*
  • Please check any of the following emotional/behavioral conditions below that you have experienced.*
  • Select, if any, substances that you have used either past or present.*
  • Are you currently, or have you been in the past two years, in counseling and/or receiving treatment with a psychiatrist, psychologist or other type of counselor?*
  • Are you currently going through any major life events or currently dealing with any major stressors? Is there anything else about your physical, emotional, or spiritual state that we should be aware of to provide spiritual support with your experience during any ceremonial session?*
  • Which of the following communities and networks do you engage with for support? Select all that apply.*

  • Plant Medicine Experience

    Please answer the following questions regarding your plant medicine experience.
  • Do you affirm the spiritual intentions of engaging with our Sacraments within the ceremonial sessions and that Sacraments of Sacred Sanctuary have specific spiritual significance and that you will only commune with the Sacraments in connection with the spiritual purposes of Sacred Sanctuary, and will not remove, sell, or gift the Sacraments for use outside of Sacred Sanctuary?*

  • Commitments, Membership and Signature

  • I commit to discontinue the use of alcohol, marijuana, recreational drugs and non-prescription medications for a minimum of 2 weeks prior to my desired ceremony weekend. I understand that many street and recreational drugs are strongly contraindicated with Ayahuasca and can be very dangerous and potentially fatal when combined.

    For any prescription medications, I commit to consulting my primary care physician and will follow any recommendations for continuing or discontinuing usage prior to and after my weekend ceremony.

    I have completed this Intake Form myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca up to and including death.

    I attest that I have read the Sacred Sanctuary Cancellation Policy below.

     

    SACRED SANCTUARY CANCELLATION POLICY
    Coordinating all the required resources for your ceremony weekend takes considerable time and resources. No refunds or discounts will be provided if you fail to arrive on time, cancel or do not show for your ceremony. If you require to cancel your participation for any reason, the cancellation policy below will apply without exception.

    IF YOU CANCEL:
    14 days or more prior to the start date of the ceremony: 100% of the deposit amount you paid for the ceremony will be transferred applied towards another a future ceremony scheduled within 12 months from the date of the ceremony in which you canceled. If you do not reschedule a future ceremony within 12 months, you forfeit 100% of the deposit money you paid.

    2-13 days prior to the start date of the ceremony: 50% of the deposit amount you paid for the ceremony will be applied towards another a future ceremony scheduled within 12 months from the date of the ceremony in which you canceled, and the remaining 50% of the deposit will be forfeited.

    24 hours or less prior to the start date of the ceremony: No refunds or credits will be given, and you forfeit 100% of the deposit amount you paid for the ceremony. No future rescheduling, and No credits will be given.

    Participants who fail to timely contact Sacred Sanctuary regarding a cancellation and fail to show up for their assigned ceremony weekend will NOT be given any refund, credit or be able to apply the deposit amount paid toward a future ceremony date.

    To cancel, you must send an email stating that you wish to cancel to: norelle@sacredsanctuaryretreat.com or lora@sacredsanctuaryretreat.com.

    IF WE CANCEL:

    If Sacred Sanctuary must cancel a ceremony, you will be refunded 100% of paid funds. Compensation for airfare, hotel and other travel related costs incurred will not be refunded. In the unlikely event that we must cancel a ceremony due to a force majeure event that is out of the control of Sacred Sanctuary (i.e. inclement weather, natural disaster, political upheaval, pandemic, epidemic, etc.) refunds are not guaranteed and may be issued at Sacred Sanctuary's sole discretion only. Sacred Sanctuary maintains the right to apply your paid funds to a future ceremony at its sole discretion.

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    CHURCH MEMBERSHIP

    I affirm that by completion and signing of this Intake Form, I accept membership as part of Sacred Sanctuary.

    I affirm that by signing this intake form, that I have reviewed all Sacred Sanctuary Church doctrinal materials on the Sacred Sanctuary website and that I wish to attend a retreat for religious and spiritual purposes consistent with the doctrines of Sacred Sanctuary. Click here to view doctrine.

    I also affirm that by signing this intake form that I have answered all the questions truthfully. Should any information in this form change, I will update Sacred Sanctuary.

  • Submit Your Required Ceremony Donation Deposit

    To reserve your spot, please send a 50% ceremony donation deposit to Sacred Sanctuary. You will be redirected after you Submit your form to our website for donation submission. Note: Your spot will not be reserved for your requested ceremony date until we receive your deposit.
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