Kambo Soulsong: Ceremony Application

 

1. Name: *

 

2. Date of Birth: *

 

3. Email Address: *

 

4. Phone number: *

 

5. Have you sat with Kambo before? If yes, how many times and please describe your experience. *

 

6. Have you worked with other plant/animal medicines? If yes, please list them. *

 

7. What are you hoping to gain or heal by working with Kambo? *

 

8. What have you tried so far to heal this issue(s)? *

 

9. Have you researched the physical effects of Kambo and are you familiar with how it affects the body/energy system? *

 

10. Are you aware that Kambo is not psychoactive, (it is a purgative ordeal medicine) and does not produce visuals as it's cousin Bufo the Sonoran Desert Toad? *

 

11. Are you willing to do integration work after your ceremony to ensure sustainable healing? *

 

12. On a scale of 1 to 10, how committed are you to making a change in your energy and in your life? If not a 10, why?
1- Not committed at all
10 - I'm all in! *

 

13. Do you have or have you had any of the following conditions: If yes, please explain.
Cardiovascular Disease
Heart Attack
High of Low Blood pressure requiring medication
Seizures
Organ Transplant
Stroke
Blood clots
Immune system disorder
Cancer/Chemotherapy
Chemotherapy implant
Parkinson's
Addison's
Donated blood plasma within 30 days
Psychological diagnosis besides Depression/Anxiety/PTSD
Pregnant or breastfeeding
Active Ulcer

*

 

14. Are you currently taking any prescribed pharmaceuticals, nutritional supplements, or over the counter medications? If yes, please list. *

 

15. Have you received an injection for COVID-19? If yes, please list the date(s).

Check out our survey templates or create your own.
Report Abuse