name
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First Name
Last Name
preferred name & pronouns
date of birth
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MM
DD
YYYY
phone
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(###)
###
####
email
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emergency contact (name & number)
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address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
how did you hear about casa de luz azul?
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google search
social media
friend / family referral
healthcare practitioner referral
alternative healing practitioner referral5
previous Casa de Luz Azul participant
other kambo practitioner referral
wellness event/expo
spiritual gathering/workshop
ayahuasca/plant medicine community
integration circle/support group
podcast
article/publication
other
current health status: please rate your overall health
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current medications & supplements: list all prescription medications, over-the-counter drugs, herbs, & supplements you're currently taking, including the dosage / amount
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major health conditions (past or present): please check all that apply
mental health support: are you currently working with a therapist, psychiatrist, or counselor?
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current alcohol use:
current recreational drug use: please be honest - this information is for safety purposes only
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substance use history: have you ever struggled with addiction or substance dependence?
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current life stressors: what major stresses or challenges are you currently facing?
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previous plant medicine experience:
previous kambo experience
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other healing modalities: what other healing practices do you work with?
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what is drawing you to kambo at this time? Please share as openly as feels comfortable
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primary healing intentions: check all that apply:
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what specific outcomes are you hoping for?
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what fears or concerns do you have about working with kambo?
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current support system: who in your life supports your healing journey?
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integration practices: how do you typically integrate profound experiences?
life situation: are you able to take time for rest & integration after ceremony?
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transportation: how will you get home after ceremony?
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spiritual practices: what spiritual practices are part of your life?
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previous spiritual/mystical experiences: have you had profound spiritual experiences, mystical states, or encounters with non-ordinary reality?
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relationship with indigenous cultures: what is your relationship with or understanding of indigenous wisdom traditions?
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dietary restrictions: any dietary restrictions, food allergies, or eating patterns we should know about?
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questions for our consultation: what specific questions do you want to make sure we address?
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understanding of donation-based model: have you read our Sacred Exchange page and do you understand our approach to reciprocity-based contributions?
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if not, please view on our "price" page
any additional information: is there anything else important for us to know before our consultation?
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consent & understanding - i understand that:
