Intake Form: One Day Retreat 8/15/2026
PLEASE READ IN ENTIRETY: Thank you for taking the time to complete this form, your interest in Kambo, and your openness to experience. Please be honest as you answer these questions. It is important that we have reliable information so we can offer you the safest and most personalized process with Kambo. You can write "n/a" for any part that does not apply to you. We will contact you to schedule a call after you've completed the form and signed BOTH the CONSENT and WAIVER at the bottom. One session costs $175-$250 sliding scale. Two sessions is $300-$350.
Name
*
First Name
Last Name
City & state where you live
*
Email
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Age
*
Approx. height and weight
*
Emergency contact name + phone number + relationship
*
Pregnant or breast feeding?
*
Yes
No
Gender + pronouns
*
Are you a veteran or current/former first responder?
*
Yes
No
What is your reason for having Kambo at this time?
*
Have you had Kambo before? If so please include the number of times, how many points/dots you had, date of last session, and how this went for you.
*
Are you hoping to alleviate a specific condition or issue (physical, emotional, spiritual, all the above, etc.) with Kambo? Please explain if so.
*
Please detail your experience with ceremonial medicine. Include ceremony type, tradition (if any), medicine, date/time frame, and dose range if you know it. Feel free to include experiences with other types of ceremony experience not involving ingestion of a psychoactive. What have these meant to you?
*
Ex. " Sweat lodge, 10x w/ first nations community... Ayahuasca, ~15 ceremonies, mostly in Shipibo tradition with the same community/practitioners in north and South America, over the course of five years, last one was two months ago"
Check any medical condition or surgery which you have or had in the past. Check the box even if you SUSPECT you have the condition but have not received an official diagnosis.
*
Heart disease of any kind (i.e., heart attacks, cardiomyopathy, valve ruptures, heart failure, arrhythmias)
Heart surgeries of any kind
Ehlers Danlos Syndrome or other collagen disorder
Aneurysms (out-pouchings/baloonings of the blood vessel wall)
Blood clots
Diabetes type 1 or 2
Strokes
ANY conditions of your blood vessels
Tears or rupture of the esophagus
Liver disease (hepatitis, alcoholic cirrhosis, portal hypertension, fluid build up, fatty liver, etc.)
Gallbladder issues (i.e., gallstones, inflammation)
Gallbladder removed
Pancreatitis (acute or chronic)
Sinus surgeries/corrections
Gastrointestinal bleeding of any kind
Crohn's disease
Ulcerative colitis
Part of the intestine surgically removed
Lyme disease
Chronic pain
Thyroid disorder
Psoriasis
Other Autoimmune conditions (i.e., lupus, MS, celiac, etc.)
Cancer (past)
Cancer (active)
Kidney disease
Organ transplant
Chest pains
Addison's disease (condition of the adrenals)
Current substance addictions
Vaccination <2 weeks ago
High blood pressure (hypertension)
Low blood pressure (hypotension)
Syncope ("passing out")
Traumatic brain injury (TBI) or concussions
Military PTSD
None of the above
Please elaborate on any of the above conditions/symptoms. Dates and timelines are particularly useful.
*
Any recent injuries/surgeries/accidents that you're recovering from? Please explain if so.
*
Have you or a family member ever been diagnosed or struggled with with any of the following... Check all that apply
*
Bipolar 1
Bipolar 2
Schizophrenia
Psychotic disorder
Borderline personality disorder
Post traumatic stress disorder
Narcissistic personality disorder
Dissociative type disorders
Other personality disorder
Delusional type disorders
Substance use disorder
Suicidality and/or self harm
None of the above
Ever had an episode(s) of mania or psychosis? If so, please elaborate below.
*
Any other chronic/nagging/recurrent issues you experience in your life?
*
List ALL medications/supplements you take. Include 1.) DOSE 2.) HOW OFTEN YOU TAKE IT 3.) FOR HOW LONG 4.) REASON YOU TAKE IT. See example below.
*
Example: "Vitamin D- 400 IU once daily- two years- for general wellness- prescribed by primary care doctor"
Do you have allergies or food/drug sensitivities? Please elaborate.
*
Ex. "peanut allergy- anaphylaxis. happened 3 times requiring epi pen and emergency room monitoring. "
Any recent major infections or unexplained fevers?
*
Do you take any of the following medications, or have you recently stopped them? Do not lie. These are very important for me to know about.
*
SSRI (Sertraline, Fluoxetine, Escitalopram, Citalopram, Paroxetine)
SNRI (Venlafaxine, Duloxetine, Desvenlafaxine, Levomilnacipran, Milnacipran)
MAOI (e.g., fenelzine)
DNRI (bupropion)
Tricyclyic antidepressants (amitryptaline, nortryptaline)
Anti-convulsants/Anti-seizure (e..g, keppra, lamotrigine, valproate)
Methylene blue
Antibiotics
Dopamine drugs (clozapine, chlorpromazine, olanzapine, quetiapine, etc.)
Tramadol
Amphetamines or other stimulants
Immunosupressants (cyclosporine, tacrolimus)
Benzodiazepenes
Barbituates (phenobarbitol, primidone)
Opioids (methadone, oxycodone, hydrocodone, morphine, oxycontin)
Antiviral drugs
Antiparasite drugs
Antimalarial drugs
Anti-nausea medications (zofran, metoclopramide, meclizine, scopolamine)
None of the above
Any drugs/medications you USED to take with regularity that you stopped over six months ago?
*
Ex. "I took steroid medication on and off for 10 years for Crohn's but stopped about 3 years ago"
Approximately how many treatments with antibiotics have you had?
*
Are you on blood thinners? (i.e., eliquis, apixaban, warfarin, lovenox etc.)
*
How often do you exercise and what do you do?
*
How are you doing with the following...
*
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very satisfied
Social connections/community
Emotional health
Adaptability
Reactiveness
Physical/sexual intimacy
Spiritual/religious life
Body pain or other symptom burden
Financial situation
Self care
Energy levels
Work/employment
Dharma/life purposes
Marijuana use
*
None
Yes, daily
Yes, frequently but not daily
Yes, occasionally
If you use marijuana, what are your motivations for doing so and what benefits do you gain from using it
*
If you use marijuana, what undesirable effects have you noticed from using it
*
What is your current relationship like with alcohol? How much do you drink, situation/environments you drink in, motivations for doing so, any desires to change the relationship, etc.
*
Do you have a history of overusing alcohol? If so, please share details including how much you drank, for how many years, and if you experienced any medical complications or hospitalizations from drinking.
*
What other drugs do you currently use recreationally and how much/how often? (i.e., cigarettes, ketamine, molly/ecstasy, cocaine, heroin, crack, fentanyl, cough syrup, nitrous, DXM, psychedelics, etc.)
*
What are some practices that might support you during the process of working with Kambo before and after?
*
Do you have people in your life that you can talk to about your experience with Kambo if you need to?
*
Yes
No
What are three things you hope to gain by working with Kambo?
*
What are some things you want to release and let go of?
*
What would a successful outcome look like to you?
*
What would a disappointing or unsuccessful outcome look like?
*
Any specific fears or concerns you want me to know about?
*
You will be required to fast for at least 10-12 hours on the day you receive Kambo. This includes medications. If you take daily medications, can you fast for at least 10 hours without going into a severe withdrawal reaction? Note that some medications may need to be stopped for longer than 10 hours.
*
Risks & Consent: MUST READ AND SIGN
Kambo can be intense but it is physically and psychologically safe for the vast majority of people. However, there are legitimate risks to everything we do in life, and Kambo is no different. Just like we would weigh the risks and benefits of a surgical procedure, driving a car, eating a hot dog, or skiing we do the same with Kambo. I will explain these risks and need you to consent to them below in order to proceed.
Herxheimer Type Reaction
Kambo may catalyze a natural detoxification process in the body that many practitioners refer to as the Herxheimer reaction. It's thought to be due to a rapid release of stored toxins (i.e., "die off") from certain cell types, though the exact mechanism is not well studied. Symptoms may include transient body aches, mood fluctuation, headaches, low energy, GI symptoms (nausea, vomiting), or rashes. Good news is that this is temporary. However, this may not be the most pleasant experience. It typically resolves after a day or so, but sometimes it lasts a few days longer.
Herxheimer Reaction RISK: Please CONSENT below
*
I have read the above paragraph about the Herxheimer Reaction. I understand the risk of a Herxheimer-type reaction with Kambo and take full responsibility for taking good care of myself after the session. I also agree to contact my Kambo practitioner with any symptoms that confuse or concern me.
Esophageal Perforation
Esophageal perforation is associated with activities that lead to vomiting and can lead to death if not rapidly treated. For this EXTREMELY rare complication, we need to be especially careful with those who have pre-existing conditions affecting the esophagus and vasculature, particularly around the neck/throat/GI tract. If after Kambo you experience strange (often sharp) pains in your body- particularly in the shoulder, the mid-upper back, belly, or throat- that move around in strange ways, or you experience difficulty swallowing, difficulty breathing, vomiting blood/food material, or persistent rapid heart rate, call your practitioner and SEEK EMERGENCY MEDICAL ATTENTION IMMEDIATELY because this could be life threatening.
Esophageal perforation RISK and WAIVER: Please CONSENT below
*
I confirm that I have read the above statement about risk of esophageal rupture/perforation with Kambo. I understand the signs and symptoms and acknowledge the risk and choose to proceed with having Kambo.
I waive ALL rights to seek or receive compensation or seek legal action against the Kambo practitioner in any case of injury, loss, discomfort, hospitalization, damage, upset or death.
Below are unique conditions that might affect the physical integrity of your esophagus. They are important for me to know, but they are NOT 100% exclusions to receiving Kambo (so don't lie!!). Select all that apply now or in the past.
*
History of endoscopies
Alcoholism
Portal hypertension
Esophageal varices
Esophageal ulcers or bleeds
Esophageal cancer
Severe stomach ulcers
Hiatal or esophageal hernias
Surgical repair of hernia
Any form of neck, chest, throat, mouth, or sinus surgery
History of frequent vomiting (i.e., due to alcoholism, bulimia, cyclic vomiting syndrome, etc.)
Severe GERD (Gastroesophageal reflux a.k.a "heartburn")
Injury or trauma to the neck or chest within the past 3 months
Infections or inflammation in the esophagus
Previous esophageal rupture/perforation
NONE OF THE ABOVE
We'll offer two sessions with Kambo. One in the morning and one in the early afternoon. Do you anticipate wanting just one round of the medicine or two?
*
Just one round
Two rounds
Unsure
Please share anything else you want me to know that will help us make this the best experience for you.
*
Submit
Should be Empty: