Facilitators sharing Retreat with HariHar
It is important we are aware of any medical conditions, medications, supplements, life experiences or habits that may influence your experience and safety. Our intention is in supporting you to have a safe, deep and beneficial experience. This is a totally confidential record and all data is safe and fully encrypted. Thanking you, with respect and gratitude for your time and your truth. You will be contacted shortly after receiving this form.
Name
*
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Whats app
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Area Code
Phone Number
What is your age
What is your sex
What country do you live
Personal Facebook link
Where did you hear about this retreat
What experience have you had with 5/Toad and other entheogen and how has it effected your life?
Have you had any formal training or supported another Practitioner? Give details.
Why do you want to be a Toad/5 Practitioner?
Do you have any training in a complimentary healing modality that may support being a Toad Practitioner?
How many times have you had Toad/5 yourself and how many times have you served Toad/5 to another?
Have you had any challenging or problematic experiences during or after your experience and if so how did you deal with it??
Why are you interested in participating in this retreat and working with these sacraments?
Do you have any concerns about doing this work or coming on this retreat? If yes, please describe?.
Do you have any current or past psychological or psychiatric conditions? If yes, please give the dates and describe the circumstances.
Have you ever experienced trauma or been abused? Was the abuse physical, mental, emotional, sexual?
Have you ever been suicidal? If yes, please give the dates and describe the circumstances.
How often do you use alcohol, drugs, or any consciousness-altering substances? Please describe generally your use of any substances throughout your life, and those you have used in the past three months and if you have or had any addiction issues.
How would you describe your health and are there any medical issues we should know about.
What Medications are you currently taking? (It is essential that we know ALL prescription, vitamins, mineral supplements and over the counter meds)
Do you or have you ever taken anti-depressants, SSRI's or MAOI's? If yes, please describe which ones, the duration of usage, when you discontinued usage, and what you are currently taking. It is imperative that we know this for your safety. *
Do you take any of the following medications
Antidepressants
Anti-anxiety meds
Blood Pressure meds
MAOI's
Steroids
Sleeping Pills
SSRI s
Are you pregnant? Or trying to become pregnant?
Do you / have you taken any of the following supplements regularly?
5-HTP
L-Tryptophan
Sam-e
GABA
L-Tyrosine
St.Johns Wort
If so give details
Personal Heath History. Check all that apply.
Bipolar Disorder
Cancer
Heart issues
Psychosis
PTSD
Schizophrenia
Diabetes
Anxiety
Depression
Do you have any allergies or any adverse reactions or side effects from any substances?
Are there any diet restrictions, or desires, or regimens that you follow? If yes, please describe.
Do you have a support network where you live? eg family, group, friends.
Do you have a friend, loved one, family member, counsellor or other trusted person(s) to speak with about this work?
Is there anything else you would like us to be aware of, or any specific questions you have?
We do our utmost to assure that you have a safe and beneficial experience, yet there are possible risks associated with this work. Therefore, it is helpful to have contact information for 2 trusted people should you need assistance getting home, or if an emergency situation arises. In the event of an emergency please give contact details of 2 trusted persons we can contact?
Please upload a recent forward facing photo of yourself.
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AGREEMENT. Please read, THEN CHECK THE BOX BELOW WITH A YES to confirm your agreement. I understand that accurate reporting of the above information is necessary to help ensure that I have a safe and beneficial experience. I realise that failure to provide accurate information may compromise my experience and I have answered this form truthfully to the best of my ability. I am responsible for my health and I understand that my participation in this event may pose some risks. To the best of my knowledge, I am in good physical condition and I am not aware of any physical or psychological infirmity, which would place me at risk to participate in any way. In the event of a medical emergency, I agree to seek emergency medical care and give permission to initiate contact with emergency medical providers. I will utilise appropriate support so that I may optimise the benefit of this experience, and reduce any risks. In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the event’s leader, organizers, hosts and participants from any and all liability, claims, demands, or course of action whatsoever arising out of, or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted. I agree to indemnify and hold harmless those with whom I engage this work. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise. In signing this release, I acknowledge and represent that I have read, understood and signed the form voluntarily; I am an adult, of at least eighteen years of age or older, and fully competent; and I execute this release for full, adequate and complete considerations fully intending to be bound by same. This waiver applies to all present and future work with this event leader. Check the box with a YES below to confirm your agreement to this release. Upon sending your form, you'll be directed to a page confirming your submission. Then we'll be in touch. Thank you.
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