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PRE-QUALIFICATION INTAKE FORM
Name
Where do you currently reside?
How did you hear about me?
What describes your relationship status?
I'm single and not looking for anyone.
I'm single and looking for my queen.
I'm in a relationship and they are 100% supportive of this work.
I'm in a relationship and we would need to talk to them first.
I'm married and 100% fulfilled.
I'm married and we are experiencing hardship.
What is your relationship to your sexuality?
Do you have an intentional self pleasure practice?
How long have you been on your spiritual journey? What was the catalyst for your spiritual awakening?
What is the biggest challenge (or challenges) you are dealing with in your life right now?
Are you currently dealing with any type of addictions and/or addictive behavior that you are wanting to address?
What is your current relationship to psychedelic medicines (if any)? Please list all psychedelics you have worked with and in what capacity.
Are you aware of any trauma you experienced as a child (big or small), or later in life as well? If so, what work (if any) have you done or currently doing to heal this?
Do you have a relationship to your inner child?
Are you currently working with a therapist or a coach in any capacity?
Are you currently taking any prescription medications? If yes, please list
What do you currently do for work? Do you feel a sense of purpose with the work you are currently doing?
What are your hobbies, what things do you enjoy doing the most?
Do you have consistent spiritual and or embodiment practices/rituals that you do daily? (ie: journaling, breath work, meditation, yoga, dance, etc)
Do you have a supportive community of brothers or sisters that you are apart of?
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