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Screening Form

Screening Questionnaire

Please note: The following section asks questions that may be sensitive in nature. Please answer as accurately as possible. This knowledge is important to ensure your safety and the safety of others while on retreat.

Which ceremony are you interested in attending
Have you ever participated in ceremony?
Are you currrently pregnant?
Please check any physical health conditions that you are currently experiencing or have experienced in the past.
Please check any psychological health conditions from the list below that you have either experienced in the past or are currently experiencing now. Please choose all that apply.
Have you ever been diagnosed, treated, or self-identified with alcohol use disorder?
What is your diet preferences
Would you be interested in participating in our post integration workshops that are held monthly

Thanks for submitting!

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