Fill Out Medical Release & Waiver 

BUFO HEALING SANCTUARY Intake, and Waiver Form

PLEASE BE 100% TRUTHFUL AND ACCURATE IN COMPLETING THIS FORM AS YOUR RESPONSES TO THE FOLLOWING QUESTIONS DETERMINE WHETHER YOU MAY SAFELY PARTICIPATE IN A CEREMONY FACILITATED BY BUFO HEALING SANCTUARY .YOU MAY BECOME A MEMBER OF BUFO HEALING SANCTUARY EVEN IF YOU ARE NOT ABLE TO PARITICPATE IN CEREMONY. PLEASE SIGN BELOW KNOWING YOU HAVE ANSWERED ALL THE QUESTIONS IN HONESTY. Thank you for allowing us to evaluate your participation for safety purposes. We are wanting to get a better understanding of who you are, what your intentions are and how we can give you the best integration services possible.

We would like to get to know YOU!

What brought you to Bufo Alvarius and to Bufo Healing Sanctuary?

Do you have any past or current physical or mental health condition? (If yes, please explain)

In the past twelve (12) months have you taken or are you currently taking any type of medications, vitamins, or supplements?

Are you currently detoxing from heavy metals and parasites? If not, would you like to learn about detoxing?

Have you ever consumed natural entheogenic/psychoactive medicines before. If yes, what were they and what were the effects?

Emergency contact name, phone number, & relationship.

Are you currently under the care of a family physician, mental health professional or any other health professional?

Have you been diagnosed by a medical professional with any of the following conditions?

Do you have any allergies? (e.g.: foods, medications, pollens/molds, chemicals, animal hair, etc.)

Have you ever been diagnosed with a mental health disorder (e.g., depression, bipolar disorder, schizophrenia/schizoaffective disorder/ paranoia/psychosis, eating disorders, obsessive compulsive disorder, suicidal thoughts/actions, self-harm thoughts or actions, impulsivities, history of violence, anxiety/panic attacks, ADHD/PTSD, any personality disorder, etc.)?

Which of these substances do you currently use or have used in the past?

What age did you start first use and age at last use of any of the substances above. (Example: Alcohol - 13, 35)

Have you ever had a spiritually transformative experience (STE) such as an out of body experience, near death experience (NDE), kundalini awakening, any Clairs, mystical or spiritual experience (not induced by a psychoactive substance? If so, please explain...

PIease type your name below. I hereby confirm that I understand the importance of answering the foregoing questions truthfully and to the best of my knowledge and ability.  This understanding is reflected in my initials at the top of this document. Therefore, I hereby represent that all answers to the foregoing screening questions are 100% truthful and accurate.  I further understand that my answers to the foregoing screening questions determine my eligibility to participate in BUFO HEALING SANCTUARY scared ceremonies; and if I am denied participation in an BUFO HEALING SANCTUARY ceremony, due to my answers to the foregoing screening questions, that such a denial is based on BUFO HEALING SANCTUARY 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 Bufo Healing Sanctuary Waiver of Liability form. I hereby warrant and represent that I am of sound mind and body and it is my belief I am mentally and physically fit to participate in an Bufo Healing Sanctuary sacred ceremony, notwithstanding its staff's determination as to my fitness to participate.

I represent that I am not currently taking any of the medications listed that are contraindicated with natural entheogenic substances, such as those to be consumed as part of the Activity, as defined herein.