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
Organ Transplant
Blood clots
Immune system disorder
Chemotherapy implant
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.