INTAKE FORM

Please take the time to complete this form. It is the first step to register for any of the offered services and retreats.

Please note that alll fields are required to move forward with registration.

Please be honest and thourough, all information is kept confidential.

If you have previously filled this form out please contact Satya directly to register.

Thank you.

First name

Last name

Email

Confirm Email

Phone

Birthday

Month

Day

Year

Who referred you (please share first and last name)

Please share a bit about yourself and what you are looking to experience

Have you ever attended a ceremony or similar retreat?

Yes

No

If you have attended a ceremonial gathering before please share what kind and how many.

Are you currently taking any pharmaceutical medications?

Yes

No

Please list any medications you are currently or have recently been taking

Please list any current or recent use of street drugs and/ or alcohol

Please list any plant medicines or assisted therepy substances currently or recently taken. If none, please write none.

Do you have any heart or blood pressure problems?

Yes

No

If any heart health problems, please explain here.

Do you have any organ or glandular problems?

Yes

No

If any organ or glanular problems, please explain here.

Have you been hospitalized or had surgery recently?

Yes

No

If recent hospitalization or surgery , please explain here.

Have you or an immediate family member ever experienced psychosis?

Yes

No

If you or an immediate family member has experinced psychosis, please explain here.

Are you pregnant?

Yes

No

Please explain any other health concerns here.

Please share any food allergies here.

I confirm that all my answers are true to my knowledge.

trinity of One

INTAKE FORM

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