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EMERGENCY CONTACT
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MEDICAL & HEALTH
(Required for Cacao + Breathwork)
Please tick any that apply:
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Heart conditions
High blood pressure
Low blood pressure
Epilepsy or seizures
Severe anxiety or panic disorders
Pregnant or breastfeeding
On strong antidepressants (SSRI/SNRI/MAOI)
On any medication affecting the heart or blood pressure
Past history of fainting, blackouts, or loss of consciousness
Respiratory issues (asthma, COPD, difficulty breathing)
None of the above
If you ticked anything, please give brief details: (Short text box)
MICRO-MEDICINE (OPTIONAL)
This part is optional. Please select:
I will be taking part in the gentle microdose
I prefer to skip this part
Not sure yet — I’d like to discuss on the day
Important: micro-medicine is not suitable if you are pregnant, on certain antidepressants (SSRI/SNRI/MAOI), have schizophrenia or psychosis, or have been advised against psychoactive substances.
Do you have any of the above?
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No
If yes, please give details: (short text box)
HAPÉ (OPTIONAL)
Would you like to take part in the grounding hapé blessing?
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Decide on the day
Do you have any nasal/sinus issues?
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No
WELLBEING CHECK-IN
Do you currently feel safe, stable, and supported emotionally?
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If no, please add more information: (short box)
Are you currently receiving therapy, counselling, or support services?
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(If yes, optional details)
AGREEMENT
Please confirm:
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I understand this is not a medical treatment or replacement for therapy
I take full responsibility for my physical and emotional wellbeing during the event
I will notify the facilitator of any changes to my health before attending
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