Ceremony Intake FormPlease, for your own safety, respond honestly to the following questions. Name * First Name Last Name Email * Phone (###) ### #### Emergency Contact Name: * Emergency Contact Relationship: Emergency Contact Phone: * (###) ### #### Is this your first experience with ceremony? Yes No If others, what others/how often/last time? What is drawing you to participate in this ceremony? Please list significant traumas (including childhood neglect and significant medical procedures) What emotional, spiritual or physical blocks are you hoping to address with this ceremony? Do you have personal history or diagnosis of mental illness, including but not limited to Bi-polar disorder or schizophrenia? * In our experience individuals with prior schizophrenia, psychosis, bipolar disorders, or manic episodes are at a higher risk after ceremony—Please, for your own safety, respond honestly to these questions. Yes No If yes, please share more: list: Does mental illness, bi-polar disorder, or schizophrenia run in your family? * Yes No If yes, who? Have you ever been diagnosed with or demonstrated the symptoms of PTSD or CPTSD? * The ceremony may be triggering to those with a history of significant trauma. Please be honest in answering the following questions. Yes No On a scale of 1-10 (1 being no anxiety and 10 being high anxiety) how would you rate your average level of anxiety throughout an average week? Are you taking any prescription or over the counter medications? * Yes No If so, please name them and include dosages: Please briefly explain any physical, emotional, psychological or spiritual abuse you have faced. Have you ever been in active combat? Yes No Are you taking any supplements or herbal medications? * Yes No If so, please name them and include dosages: If you have a heart condition or untreated high blood pressure, we will not be able to accommodate you for a retreat. * By initialing below you are indicating you have no known heart condition or untreated high blood pressure. Receiving a Covid shot or Covid booster shot within 30 days prior to the ceremony is contraindicated. * By initialing below you are indicating you have not received a shot in the last 30 days. Do you have asthma? Yes No If so, please share the severity and triggers to an asthma attack: Are you prone to dizziness, fainting, stroke, epilepsy, or vertigo or a seizure disorder? * Yes No If so please explain: Are you pregnant or breastfeeding? Yes No Please list any allergies or food intolerances: * Receiving a Covid shot or Covid booster shot within 30 days prior to the ceremony is contraindicated. Participants with a history of schizophrenia or psychotic episodes, ceremony can induce prolonged psychosis. A history of schizophrenia or psychotic episodes precludes participation. Participants who are at risk of heart attack and stroke, bipolar disorder, manic episodes or a history of schizophrenia or psychotic episodes cannot and shall not participate in the ceremony. Certain medications are also contraindicated. Please make sure you have disclosed any and all drug use both prescribed and recreational in the above sections. * Please check Yes below if you understand and agree that you have provided accurate information. Check No if you do not understand and need to be contacted to receive more information. Yes No Ceremony Release Waiver * By checking "yes" below you are indicating that you understand the following: I understand that this ceremony includes physical movement, breath, meditation, release of emotions, touch, bodywork and sound. I understand that these modalities give an opportunity for release of chronic muscular tension and help to increase the free flow of energy in the body. As is the case with any physical activity, the risk of injury, even serious disabling, is always present and cannot be entirely eliminated. I assume full responsibility for any and all damages, which may incur through participation. I understand that the facilitator does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals. I understand that participation in the ceremony is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have. I confirm that I am not pregnant, nor have severe asthma, severe heart disease, a mental illness, epilepsy/history of seizures. Ceremony work is not recommended under certain medical conditions. These are contraindications, to which I have been made aware of in the above document. I will make the facilitator aware of any medical conditions or physical limitations before the ceremony. To the best of my knowledge, I am not aware of any physical or physiological infirmity, which would place me at risk to participate in any way in the ceremony activities. I am fully aware of the risk and hazards connected, with this ceremony. I affirm that I alone am responsible for deciding whether to participate in this Ceremony, and that participation is at my own risk. I acknowledge and affirm that my participation in any on-property activities such as, but not limited to, the use of the sauna, hot tub, and cold tub, is solely voluntary and I accept full responsibility for any associated risks involved and release any liability. I am aware that these methods and medicines have been used safely and to great benefit by many people throughout the world, and for many generations. I am also aware that it is possible I will encounter sensations, emotions, and/or memories, which may make me uncomfortable. I understand that experiencing these things, and working through them, may be an essential step in my growth as an individual. I pledge to make a good faith effort to be fully engaged throughout the experience. However, I understand that I am participating fully voluntarily, and that I may choose to not participate in any aspects of the group experience that make me uncomfortable, or to which I feel an aversion. In the event I am uncomfortable, or feel that the intensity of the journey is too much, I understand that the facilitators are there to help me. In the event of any seemingly adverse reactions, I will trust the experience and judgment of the facilitators to help guide me through these times. To allow the facilitators to best serve my interests, I have disclosed medical or psychiatric conditions I may have. I am also providing the contact information for a trusted person who can be notified in the unlikely event I need outside help. I hereby release and agree to hold Micah McLaughlin, Sarah Berry, Continuum Healing and the property owners of 3370 Alden Nash Ave SE Lowell, MI 49331 harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the homeowner, or that may otherwise arise in any way in connection with this ceremony. I understand that this release discharges Continuum Healing, Micah Mclaughlin, Continuum Healing and the property owners from any liability or claim that I, my heirs, or any personal representatives may have with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to this ceremony. This liability waiver and release extends to all entities, properties, owners, partners, facilitators and employees associated with 3370 Alden Nash Ave, SE Lowell MI 49331 or Continuum Healing LLC. Yes, I Understand No, I do not understand and need further information. Name * First Name Last Name Date * MM DD YYYY Thank you!