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Kambo Body Bliss Retreat Application Form

Thank you for considering the Kambo Body Bliss Retreat!

To ensure the retreat aligns with your expectations, kindly complete this form.

We'll review it promptly and notify you via email regarding its approval.

Upon approval, your spot will be reserved for 48 hours awaiting payment.

Looking forward to connecting with you.


With love,

Aluna Lua & AA Team

 

7 minutes 🕖

Start

Tell Me About Yourself 😊

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Question 2 of 34

Name

Question 3 of 34

Phone # (Optional)

Question 4 of 34

Email

Question 5 of 34

Where would you be coming from?

Question 6 of 34

What Are Your Preferred Pronouns?

A

He / His

B

She / Hers

C

They / They

D

Other

Question 7 of 34

Would you please share who referred me to you and how did you find the page with this form?

Question 8 of 34

Please share your Instagram or Facebook handle

Question 9 of 34

What is your #1 Emergency Contact? (please share their name, relationship with you, email and phone number)

History And Experience 🌿

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Question 11 of 34

What calls you to join our retreat at this time?

 

Can you provide any details about what the past few weeks or months have been like? 

Question 12 of 34

What are you interested in attending?

A

Entire experience (10 days: 4 days in-person retreat + 6 integration cleanse program)

B

In-person ceremony only

C

Body Bliss Cleanse Online Only

D

10-day journey privately

Question 13 of 34

Will this be your first time working with Kambo?

A

Yes

B

No

Question 14 of 34

What is your experience with the medicines of Hapé, Sananga and Cannabis?

What other plant medicines are you experienced in?

How's Your Health?⭐

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Question 16 of 34

How would you describe your gut health?

 

Please share any physical health conditions we should know to best support you.

Question 17 of 34

Do you have high blood pressure, diabetes, or heart conditions?

 

Please describe further below.

Question 18 of 34

Do you have any blood-borne diseases, like Hepatitis, Herpes, HIV or others.

If yes, describe for how long, symptoms you experience and medications you might use for it.

 

Question 19 of 34

Do you take any medications or supplements regularly, including prescription, over-the-counter, and natural medications?

 

If yes, which ones? Please explain the reason for use

Question 20 of 34

Are you allergic to any medication or specific foods?

 

Please specify which ones and the reaction that results when you ingest it.

Question 21 of 34

What is your current, subjective psychological status?

 

Are you currently working with a therapist or psychiatrist?

 

Please share any psychological health conditions that we should know to best support you.

Question 22 of 34

Do you smoke or use tobacco products?

 

What kind of tobacco product do you use? And how often? for how long?

Question 23 of 34

Are you pregnant or breastfeeding?

 

If yes, for how long?

Question 24 of 34

Have you ever been hospitalized for a psychiatric reason or seriously considered ending your life?

 

If yes please describe further below.

Question 25 of 34

Have you ever been diagnosed, treated, or self-identified with alcohol use disorder, drug addiction or any other substances or activities?

 

Please describe further below.

 

Question 26 of 34

Have you used any of the following substances in the past 3 months?

A

Cocaine

B

Heroin

C

non-prescription Opiates

D

Methamphetamine

E

None

Question 27 of 34

Have you experienced any kind of traumatic incident in your past that you would like us to know about?

How Can We Help? 🌈

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Question 29 of 34

What are your current life dreams and goals?

Question 30 of 34

Do you currently work or are you interested in working as a space holder, ceremony guardian, guide, trip sitter, etc?

 

If so, describe your experience or calling further below.

Question 31 of 34

Do you need a payment plan in order to commit to this journey?

Question 32 of 34

Would you like to schedule a call with one of our team members before deciding to invest in the Kambo Body Bliss Initiation?

A

No, I am fully committed to this experience and do not need a call.

B

Yes, I would like to speak with a team member before making my decision.

Question 33 of 34

Do you need to talk to your partner, parent or anyone else before making this investment?

If yes, please describe your needs below.

Question 34 of 34

Anything else you’d like me to know about you?

Confirm and Submit