Sacred Earth Sanctuary

Rooted in earth. Open to spirit.

Intake Screening Form

You must be 100% truthful and accurate in completing this form. Your responses determine whether you may safely participate in a Sacred Earth Sanctuary ceremony. Please read carefully and initial your agreement below before proceeding.

Your responses are held in the strictest confidence possible.

Personal Information
Format: yyyy-mm-dd
This will be used for all future Sacred Earth Sanctuary activity.
Please provide the full name and membership number of your referrer.
Spirit & Practice
Entheogenic Experience
Intention & Inner Life
Background & Lifestyle
Health & Wellbeing
Ceremony Preferences
Attestation

I hereby confirm that I have answered all questions above truthfully and to the best of my knowledge and ability. This understanding is reflected in my agreement at the top of this form. I understand that my answers determine my eligibility to participate in Sacred Earth Sanctuary ceremonies; and if I am denied participation in a sacred ceremony due to my answers, that such a denial is based on Sacred Earth Sanctuary's determination that my exclusion is for the safety and benefit of myself and other ceremonial participants.


I understand that this screening form is attached to and made part of Sacred Earth Sanctuary's Waiver of Liability form.


I hereby warrant and represent that I am of sound mind and body. It is my belief I am mentally and physically fit to participate in a Sacred Earth Sanctuary ceremony, notwithstanding its medical staff's determination as to my fitness to participate.

Sacred Earth Sanctuary · Salisbury, MA
Thank you

Your intake screening form has been received. We will review your responses with care and be in touch within several weeks.

We are grateful for your patience and your trust.