Forms

Divine Light Integration » Forms

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Name*

First Name Last Name

Phone*

Email*

BirthDate*

MM slash DD slash YYYY

Emergency Contact Information and Relationship:*

PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND HONESTLY AS POSSIBLE. YOUR RESPONSES WILL REMAIN STRICTLY CONFIDENTIAL.

What are the top 3 things that you are hoping you may gain from this work?

What are the top 3 things you are hoping you may let go of or leave behind by doing this work?

Please describe any previous experience working with Psychedelics: therapeutic or recreational?

Do you have a preferred method of personal development or what may be called a spiritual practice or discipline? If so, how would you describe it?

Do you drink alcohol?*

Yes

If yes, please describe what type, how much, and how often*

Do you use caffeinated products?*

Yes

If so, please describe what type, how much, and for how long*

Do you use cannabis products?*

Yes

If so, please describe what type, how much, and for how long*

Do you exercise or engage in physical activity?*

Yes

If so, please describe what type and how often*

Please describe your diet in terms of what you eat in a typical day (be honest with us and yourself!)

What is your current living and social situation? Do you have a partner, children, etc.?

Please share any other information with regards to a substance, behavior or thought pattern you might be struggling with.

Declaration*

I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good. (Answer yes and add full name)

Please type your full name and today's date below to complete this form*

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We are spiritual beings having a human experience, not human beings having a spiritual experience.”

~ Pierre Tailhard de Chardin

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