Your details How we reach you, and who we call if something goes wrong.
Preferred name (if different) Date of birth * Mobile phone * Mailing address (street, city, state/region, postal code, country) * Emergency contact — full name * Emergency contact — phone * Emergency contact — relationship to you *
Ceremonial experience Have you previously participated in a sacramental, psychedelic or entheogenic ceremony? *
Which medicine(s), roughly when, and how many times have you sat with Bufo (5-MeO-DMT)? *
Have you attended a ceremony with us before? *
Approximately when, and where (city, state)? *
Your intentions There are no right answers here — this helps us hold you well.
What is calling you to this experience? * What are your current life challenges? * What would you like to gain from this experience? * Are there trauma triggers you would like us to be aware of? Please describe. Who are the most important people in your support network, and is anything lacking there? Does your immediate family support you having this experience? *
Does any of this apply to you? * (select all that apply)
Previous experience with meditation, altered states or shamanic work — please describe Significant trauma (childhood or adulthood), losses or grief you'd like us to know about Medical history Answer honestly. Only your facilitator sees this, and some answers determine whether it is safe for you to sit.
Allergies Are you pregnant or breastfeeding? *
Do you have a diagnosis of a terminal medical condition? *
Diagnosed — heart, circulation and neurological * (select all that apply)
Diagnosed — respiratory, metabolic and other * (select all that apply)
Please explain any medical conditions you checked above Have you been hospitalized for a medical condition in the past 12 months? *
What for, and approximately when? *
Mental health Diagnosed mental health conditions * (select all that apply)
Have you ever experienced any of the following? * (select all that apply)
Has an immediate family member been diagnosed with any of the following? * (select all that apply)
Please explain any mental health answers above Are you currently under the care of a psychiatrist, psychologist, therapist or counsellor? *
Have you experienced suicidal thoughts within the past 12 months? *
Please tell us more — when, and whether you have support in place *
Have you ever attempted suicide? *
Approximately when? *
Have you ever been hospitalized for a psychiatric or emotional issue? *
Reason/diagnosis and approximate date of last hospitalization *
Medications & substances Interactions matter enormously with 5-MeO-DMT. Please list everything.
List ALL medications, supplements, hormones, peptides and injections you currently take, with dosage and frequency * Medication groups Please go through each group below. Tick “none in this group” if none apply — we need an answer for every group, not just the ones that do.
Antidepressants and psychiatric medication * (select all that apply)
Stimulants, sedatives and pain medication * (select all that apply)
Heart, blood pressure and breathing * (select all that apply)
Hormones and metabolic medication * (select all that apply)
Supplements and herbal remedies * (select all that apply)
Do you use any of the following? * (select all that apply)
If you use any of the above, please describe frequency and amount Have you ever had a substance abuse issue? *
Please tell us more, including how long sober if applicable *
Identity We verify identity before ceremony. Your document is deleted 30 days after the event.
Agreements Please read each of these carefully before signing.
Medical disclaimer
We and our representatives are not licensed medical professionals and do not provide medical advice, diagnosis, treatment, or healthcare services. Any information shared before, during, or after ceremony is offered solely for educational, spiritual, and informational purposes and should not be interpreted as medical advice.
Participants should never discontinue, adjust, or modify prescribed medications without first consulting their prescribing physician or qualified healthcare provider. Participation in ceremony is not intended to diagnose, treat, cure, or prevent any physical or mental health condition.
By checking below I acknowledge that:
• I have read and understand this medical disclaimer.
• I understand no medical advice or healthcare service is being provided.
• I agree to consult my physician regarding my medications and medical conditions.
• I certify the information I have provided is accurate and complete.
• I understand that withholding relevant medical or psychological information may place me at risk.
• I understand participation is voluntary and that completing this form does not guarantee acceptance into a ceremony, and that participation may be postponed, rescheduled or declined if safety concerns arise.
* Informed consent, assumption of risk, and release of liability
Please read carefully. By checking below you acknowledge that you have read, understood, and voluntarily agree to all terms contained here.
ELIGIBILITY. I certify that I am at least twenty-one (21) years of age and legally capable of entering into this agreement.
VOLUNTARY PARTICIPATION. My participation in any ceremony, event, retreat, training, gathering or sacramental experience is completely voluntary. I may decline participation at any time prior to receiving any sacrament, and I am not being coerced, pressured or influenced by anyone.
SPIRITUAL NATURE. This is a religious and spiritual organization and the sacrament offered — 5-MeO-DMT (Bufo Alvarius) — is provided solely within a spiritual, religious, ceremonial, educational and personal-growth context. No particular outcome, healing, insight, breakthrough, transformation or benefit is guaranteed. Spiritual experiences are subjective and vary significantly between participants.
DISCLOSURE OF HEALTH INFORMATION. I certify that all information provided in my intake and screening is truthful, complete and accurate to the best of my knowledge. I understand that withholding information regarding medical conditions, psychiatric conditions, medications, supplements, substance use or personal history may increase the risk of adverse outcomes. I agree to notify the organizers immediately of any change to my physical health, mental health, medications, supplements or circumstances prior to participation.
ASSUMPTION OF RISK. I understand that participation may involve substantial, serious and unforeseeable risks, including but not limited to: intense emotional and psychological experiences; altered states of consciousness; physical discomfort; elevated blood pressure; changes in heart rate; anxiety, fear, panic, confusion; dizziness or loss of balance; nausea and vomiting; emotional release; recollection of traumatic memories; psychological distress; spiritual crisis; physical injury or falls; aggravation of known or unknown medical conditions; unexpected reactions; serious injury; permanent disability; and death. I acknowledge that no screening process can eliminate all risks, and I knowingly and voluntarily assume all known and unknown risks associated with my participation.
EMERGENCY MEDICAL CARE. In an emergency I authorize the organizers and their representatives to seek emergency medical assistance on my behalf if deemed necessary. I understand I am solely responsible for all costs associated with emergency treatment, transportation, hospitalization, physician services and related expenses.
RELEASE OF LIABILITY. To the fullest extent permitted by law, I voluntarily release, waive, discharge and hold harmless the organization, its ministers, facilitators, volunteers, contractors, employees, officers, directors, agents, representatives, successors and assigns, together with the owner of any property where a ceremony, event, training, retreat or gathering is held and any landlord, property manager, host or venue provider, from any and all claims, demands, causes of action, damages, losses, injuries, liabilities, costs, expenses, attorney fees or legal actions of any kind arising from or related to my participation, including claims arising from negligence, to the maximum extent permitted under applicable law.
COVENANT NOT TO SUE. I agree that I shall not file, initiate, participate in or maintain any lawsuit, claim, complaint, arbitration, administrative action or legal proceeding against any released party for any claim arising out of or related to my participation. I understand this is a material condition of my participation.
INDEMNIFICATION. I agree to defend, indemnify and hold harmless all released parties from any claims, damages, liabilities, losses, attorney fees or expenses arising from my actions, conduct, participation, omissions or breach of this agreement.
REFUND POLICY. I understand that all registrations, donations, contributions, tuition, retreat payments, deposits and event fees are subject to the organization's refund, cancellation and rescheduling policies.
ACKNOWLEDGEMENT. I am at least 21 years of age. I have carefully read this entire agreement and fully understand its contents. I understand that I am waiving important legal rights. I voluntarily assume all risks associated with participation, release the parties above from liability, and agree not to sue. I sign this agreement freely, voluntarily and without coercion.
* Media release — may we use photos, video or testimonials containing your likeness? *
Today's date * How did you hear about us? *
Would you like to join our mailing list?
Questions and concerns This sends a request — The Temple Lotus will schedule a time with you.
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