Hummingbird Church Intake Form 

The following form helps us understand a little bit more about you and how we can best ensure that you have a meaningful and safe experience during our sacred healing ceremonies. Please take into consideration that this is a religious ceremony, not a medical or wellness procedure or facility.

You are required to complete this intake form before you will be eligible to participate in any of our sacred ceremonies. 

You are not eligible to participate in a sacred healing ceremony if; you are under the age of 21, in your first trimester of pregnancy, you have a history of psychosis and or schizophrenia, have been diagnosed with a personality disorder, current active medicated bipolar disorder, history of seizures or diagnosis of epilepsy, current anorexia and or bulimia, experienced a stroke or embolism, severe asthma or emphysema, a known cardiac illness, uncontrolled high blood pressure, Crohn disease, irritable bowel syndrome, ulcerative colitis, or intestinal ulcers, surgery within the last three months on any part of your digestive system or liver disease.

For health and safety reasons you cannot attend a sacred healing ceremony if at the time of the retreat you are taking SSRIs, recreational drugs, have taken any medication or supplements 24 hours prior to the ceremony.

All of your responses are entirely confidential. Please read each question and answer carefully. If you would prefer not to answer a question, please leave it blank.