Lois Koffi Application Form

1
What's your name?* This field is required.
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What's your email?* This field is required.
example@example.com
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Please list ALL medications and supplements you currently take regularly, including what for and dosage.* This field is required.
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What medical or health issues do you currently have?* This field is required.
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Have you used plant medicine before either recreationally OR in ceremonial setting?* This field is required.
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If yes, what dosage? Which medicine? When/where was the set/setting?* This field is required.
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What are your top 3 intentions or goals with plant medicine?* This field is required.
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Please list any substances or addictions you have (ie sugar, alcohol, cannabis)* This field is required.
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What is your current spiritual or religious practice?* This field is required.
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Please list any specific life traumas you have experienced that are holding you back in your life (if you believe in past lives, share also past lives or ancestral traumas you are aware of)* This field is required.
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How is your sleep and how much do you get every night?* This field is required.
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Please list example of daily nutritional intake - food and beverage for all meals/snacks* This field is required.
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What are your top fears or limiting beliefs?* This field is required.
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Who is your current support system? List any/all family /friends or therapists that support you* This field is required.
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15
Who referred you?
Should be Empty: