Wachuma Application | soulfulhealing

Wachuma Microd♥️sing Journey

Application & Safety Screening

INVESTMENT: $999 USD (Only 5 spaces available)

This experience is offered through an application process to make sure it is appropriate for each individual.

Please complete the confidential form below as honestly as possible.

Submission of this form does not automatically confirm your place. I will personally review your application before we proceed.

1. About You

Full name

Birthday

Month

Day

Year

Email

WhatsApp / Phone

Where are you currently based?

Emergency contact: Name, relationship and phone number

2. Your Intention

What is bringing you to this experience at this point in your life?

What is your intention for the ceremony?

What are you hoping to heal, understand, release or gain clarity around?

What would a meaningful outcome look like for you?

3. Previous Healing Work

Have you ever been in therapy, counseling or coaching?

Yes

No

Are you currently working with a therapist, psychologist or psychiatrist?

Yes

No

Have you previously explored somatic work, breathwork, meditation, hypnotherapy or other healing modalities?

Yes

No

4. Previous Psychedelic / Plant Medicine Experience

Have you ever worked with psilocybin/mushrooms or other psychedelics/plant medicines?

Yes

No

5. Mental Health

Have you ever experienced psychosis, mania, hallucinations, delusions or loss of contact with reality when not under the influence of a substance?

Is there a history of bipolar, schizophrenia, or psychosis in your immediate family?

Have you ever been hospitalised for a mental health reason?

During the past month, have you had thoughts of harming yourself, ending your life or not wanting to be alive?

Have you ever attempted suicide or seriously harmed yourself?

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