YOU MUST BE 100% TRUTHFUL AND ACCURATE IN COMPLETING THIS FORM AS YOUR RESPONSES TO THE FOLLOWING QUESTIONS DETERMINE WHETHER YOU MAY SAFELY PARTICIPATE IN A DREAMTIME CHURCH CEREMONY. PLEASE INITIAL BELOW IF YOU UNDERSTAND THE NEED TO ANSWER THE FOLLOWING QUESTIONS TRUTHFULLY AND ACCURATELY.

Initials *

In addition to allowing us to evaluate your participation for safety purposes, this form also allows us to get a better understanding of what your intention(s) is in joining us for a scared ceremony.

1. We ask that you listen closely to what has drawn you to ceremony. Take some time to meditate and be with your heart’s intention. Please share those insights with us. *

2. Do you have a history of, or currently suffer from any serious health condition or mental illness? *

Yes

No

3. Have you had a psychotic breakthrough or been diagnosed with bi-polar at any point in your life? *

Yes

No

4. Have you in the past 2 years have been in the care of a therapist or a mental health professional? Have you ever experienced any traumatic or emotional conditions that are relevant to this retreat, including childhood emotional or physical abuse? *

Yes

No

5. Are you currently or have you been taking (in the past twelve (12) months) any type of medications? *

Yes

No

6. Have you ever consumed natural entheogenic/psychoactive medicines before? *

Yes

No

7. Do you have any experience consuming natural entheogens in a sacred or ceremonial context? *

Yes

No

8. Do you have any food allergies or restrictions? *

Yes

No

9. We post photos of ceremony on social media to share and spread the word of the amazingness of plant medicines. Would be ok with your photo being posted on social media? Your name will not be mentioned or tagged nor the actual plant medicine used. *

Yes

No

10. What is your room preference? *

Private

Shared

Either is fine.

If you are open to sharing, is there someone you'd like to share with?

ATTESTATION

Please check each box to confirm that you understand the following disclaimers*.

I hereby confirm that I understand the importance of answering the foregoing questions truthfully and to the best of my knowledge and ability. This understanding is reflected in my initials at the top of this document.

Therefore, I hereby represent that all answers to the foregoing screening questions are 100% truthful and accurate. I further understand that my answers to the foregoing screening questions determine my eligibility to participate in Dreamtime Church’s sacred ceremonies; and if I am denied participation in a Dreamtime Church ceremony, due to my answers to the foregoing screening questions, that such a denial is based on Dreamtime Church’s determination that my exclusion is for the safety and benefit of myself and other ceremonial participants.

I understand that this screening form is attached to and made part of Dreamtime Church’s Waiver of Liability form.

I hereby warrant and represent that I am of sound mind and body and it is my belief I am mentally and physically fit to participate in a Dreamtime Church ceremony, notwithstanding its medical staff's determination as to my fitness to participate.

I'm excited to start working together. Please type your full name below to confirm the above statements and let's get started!

Participant's Full Name *

E-Mail Address of Person Signing *

Contact Number/Mobile: *

Electronic Signature

Print your name

Review your signature

Draw your signature

Type It
Draw It
Clear

Date & Time

Women's Retreat Intake Screening Form