PLEASE answer all questions AS FULLY as possible for safety purposes. All information is STRICTLY CONFIDENTIAL.

Full name*

Birthday*

E-mail*

Phone number*

Do you use any of those apps?*

Signal app

None

Please tell us the name of the person who connected you to us. *

Have you been in this specific type of ceremonial retreat before?*

Yes

What date are you coming to the ceremonial retreat?*

We ask a donation to cover the expenses and affords necessary to make the retreat happened. We are able to provide you a tax deductible receipt if you would like to offer an extra donation to Somatree Unity.*

Are you coming to the ceremonial retreat to overcome alcoholism, any drug addiction, or a specific personal trauma? If the answer is YES, we would like to learn more about it on our call interview.*

Yes

Are you currently taking any kind of medication including antidepressants? IT IS ABSOLUTELY IMPORTANT to list all of them explaining what each*

Are you currently taking any kind of supplements, herbs etc? Please list all of them.*

Have you ever had a serious illness such as: cardiovascular disease including any heart-related issues, high blood pressure, contagious diseases, glaucoma, epilepsy, asthma or another health conditions?*

Do you have any allergies? Please explain how severe has been your allergies and what medications help you.*

Are you currently on any alternative treatment, detox, etc? Can you describe it?*

Have you ever had a surgery? What for? How long ago?*

Do you drink ALCOHOL? How often? IT IS ABSOLUTELY NECESSARY to let us know if you have an alcoholic habitat for your own safety.*

Are you trying to quit smoking TOBACCO?*

Have you ever suffered or are you currently suffering any psychiatric disorder? Can you describe it? Have you ever been admitted to a psychiatric clinic?*

Are you part of any religion or spiritual path? Can you briefly describe it?*

What date is today?*