Participant Intake - Dragonfly Temple

Please enable JavaScript in your browser to complete this form.

The following form helps us understand a little bit more about you and how we can best ensure that you have a meaningful and safe experience during our sacred healing ceremonies. Please take into consideration that this is a religious ceremony, not a medical or wellness procedure or facility.

All members must complete an intake form prior to attending ceremony. First time participants will be required to complete an additional screening via phone call.

All of your responses are entirely confidential. Please read each question and answer carefully. If you would prefer not to answer a question, please leave it blank.

Please provide date and City,State in which you attended a Bufo ceremony with Temple of Eden and/or Suzi Kalypso?

For health and safety reason you cannot attend a ceremony if have taken SSRIs within 2 weeks, recreational drugs and any medication within 3-4 days, and supplements 24 hours prior to ceremony.

You are ineligible to participate in a sacred healing ceremony if; you are under the age of 21, in your first trimester of pregnancy, you have a history of psychosis and or schizophrenia, have been diagnosed with a personality disorder, current active medicated bipolar disorder, history of seizures or diagnosis of epilepsy, current anorexia and or bulimia, experienced a stroke or embolism, severe asthma or emphysema, a known cardiac illness, or uncontrolled high blood pressure.

Please enable JavaScript in your browser to complete this form.

Participant Intake Form

Participant Information

Have you ever experienced any of the following:

Please use this section to share any questions or concerns you have.

Medical Information

Please provide the information requested below, as it may be needed in case of an emergency.

Please select the response that best describes you: