Medicine Ceremony - Application Form

Medicine Ceremony Application & Intake Form

Thank you for your interest in participating in a medicine ceremony with us. We ask that you complete this form as thoroughly as possible with complete honesty, so that we can be aware of any contraindications or risks, and so that we can be proactive in discerning whether this experience would be a suitable fit for you at this time. Everything shared in this form will be held confidential by us. Please note that this application will take about 15 minutes to complete. - Alyona & Alexandre
What is your full name? (as it appears on your passport)
What is your preferred first name?
What is your mobile number? (Whatsapp and/or Signal)
Please enter a valid Whatsapp or Signal phone number.Format: (000) 000-0000.
Email
example@example.com
Confirm your email
example@example.com
What is your relationship status?
I.e Single, Married, Divorced, Partnered, etc.
What is your date of birth?
What is your height?
In Centimeters
What is your weight?
In Kilograms
What is your nationality and passport number?
What is your city and country of residence?
How did you find out about this ceremonial offering? If you were recommended by someone, can you please include their name?
Have you travelled internationally before? If so, where? Have you travelled to Cusco or the Sacred Valley before?
Please provide the details of an emergency contact person.
Include full name, email, contact number (with country code), and their relationship to you
Are you currently employed? If so, what is your work/profession?
Please click if you have any of the following, or if you have ever been diagnosed in the past with any of the following:
If you clicked on any of the above, please explain more about the condition(s) including whether there has been any resolution or whether these diagnoses/issues are still persistent in your life.
Do you have a history of, or do you currently have, any medical conditions (i.e: not psychiatric diagnoses) that were not listed in the above question? If yes, please explain.
Are you currently taking any prescription drugs? Please include dosage, frequency, and purpose of use
Has there been a history of psychosis, schizophrenia, bipolar, mood disorders, or other severe mental illness in your family?
Have you ever seen a psychologist or psychiatrist for any mental health issue or crisis, and been diagnosed with any of the following conditions listed below?
If you clicked on any of the above conditions, please explain more about your past and/or current situation with them.
Have you ever been hospitalized for medical or psychiatric reasons in your life? If so, please elaborate on the context of this hospitalization(s).
Have you ever taken, or are you currently taking, antidepressants, antipsychotics, or benzodiazapines? Please share the name of the medication, dosage, frequency, and what you're taking this for.
Do you currently struggle with any addictions, or do you have a past history of addictions? Please describe thoroughly below.
Do you use recreational substances, such as cannabis, cocaine, methamphetamines, etc.? If so, please describe your use.
Do you currently use alcohol? If so, how often do you use alcohol?
Do you have any experience with teacher plants or psychedelic substances in any capacity? Please describe previous use, including context(s).
Have you experienced overwhelming side effects or have you had very difficult experiences that you have not been able to integrate from working with psychedelics, plant medicines, or expanded states of consciousness?
Are you pregnant?
Do you currently have a therapist, mentor, and/or support group?
List any food or drug intolerances/allergies here.
What is your preferred food diet? Any strong dislikes?
i.e vegan, vegetarian, pescatarian, omnivore, etc.
Do you have any strong sensitivities or intolerances to scents/smells? Please describe.
Are there any major sources of stress in your life at the moment, or any symptoms that you are experiencing, which are impacting your health and well-being?
Are you experiencing any forms of psycho-spiritual crisis (i.e spiritual emergency)? If yes, please provide some brief detail of what you're experiencing.
Do you have a self-care, embodiment or spiritual practice that you engage in? If yes, what is it and how many times a week?
What makes you feel connected and resourced in your life? Please list at least 3 people, practices, or things that support you to feel resourced in your life.
Do you identify with any religious or spiritual beliefs? Please describe.
What are your motivations and intentions for wanting to participate in a ceremony with us?
Do you have any strong expectations, fears and/or concerns for engaging in a sacred medicine ceremony with us?
In some cases, it is possible that we will offer a mystery sacred medicine ceremony in which the contents of the brew will not be revealed or shared with you. Is this something that you feel comfortable with? Please know that we will have a more elaborate conversation with you to discern and discuss which medicine or brew we believe is appropriate based on your intentions and needs.
As part of this ceremonial experience, we require that you engage with us for 1 preparation session prior to the ceremony, and 1 integration session after the ceremony. These are included in the cost of the ceremony.
Payment Details & Next Steps

After reviewing your application, we will be in touch via email to arrange a 45-minute discovery call. This conversation offers an opportunity for us to get to know one another, explore your intentions and any questions you may have, and mutually discern whether engaging in a sacred medicine ceremony together is the right fit for all involved. In the spirit of Ayni (sacred reciprocity), our exchange for individual ceremonies is offered on a sliding scale of $400–$600 USD. Upon acceptance, we ask that you secure your ceremony date by submitting a non-refundable deposit of 50% of the total exchange via WISE transfer (plus any applicable transfer fees). The remaining balance is due prior to your ceremony and may also be paid by WISE transfer. If you have any questions about the application process, payment, or the next steps, please don't hesitate to contact us at contact@ahealingbridge.com. We are happy to support you.
Based on our sliding scale of $400-600 USD, please confirm below the amount you would like to pay as part of the financial exchange:
What is your preferred date for this ceremony?
Please check our webpage for available ceremony dates
Would you like to be added to our mailing list to receive updates on our offerings, workshops and upcoming events?
Please upload a clear photo of yourself (Max 10.6 MB). We will only use this photo to identify you throughout the application process.

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Declaration Signature: By signing here, I confirm that everything I have shared in this intake form is honest and true, and that I did not withhold any important information about my medical, psychological/emotional, and physical health and well-being. If anything changes between the time I complete this form and the date of the ceremony, I commit to informing Alyona Kobevka & Alexandre Jodun of these changes as soon as I become aware of them.
As a reminder, please click the "SUBMIT" button below in order to officially complete this application. If you do not click submit, we will not receive your application and you may lose your responses.
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Medicine Ceremony Application & Intake Form

Payment Details & Next Steps