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 🕖
------------------------------------
Question 2 of 31
Name
Question 3 of 31
Phone # (Optional)
Question 4 of 31
Email
Question 5 of 31
Where would you be coming from?
Question 6 of 31
What Are Your Preferred Pronouns?
He / His
She / Hers
They / They
Other
Question 7 of 31
Would you please share who referred me to you and how did you find the page with this form?
Question 8 of 31
Please share your Instagram or Facebook handle
Question 10 of 31
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 11 of 31
What are you interested in attending?
Entire experience (10 days: 3 days in-person + 7 online)
In-person ceremony only
Body Bliss Cleanse Online Only
Question 12 of 31
Will this be your first time working with Kambo?
Yes
No
Question 13 of 31
What is your experience with the medicines of Hapé, Sananga and Cannabis?
Question 15 of 31
How would you describe your gut health?
Please share any physical health conditions we should know to best support you.
Question 16 of 31
Do you have high blood pressure, diabetes, or heart conditions?
Please describe further below.
Question 17 of 31
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 18 of 31
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 19 of 31
Are you allergic to any medication or specific foods?
Please specify which ones and the reaction that results when you ingest it.
Question 20 of 31
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 21 of 31
Do you smoke or use tobacco products?
What kind of tobacco product do you use? And how often? for how long?
Question 22 of 31
Are you pregnant or breastfeeding?
If yes, for how long?
Question 23 of 31
Have you ever been hospitalized for a psychiatric reason or seriously considered ending your life?
If yes please describe further below.
Question 24 of 31
Have you used any of the following substances in the past 3 months?
Cocaine
Heroin
non-prescription Opiates
Methamphetamine
None
Question 26 of 31
What are your current life dreams and goals?
Question 27 of 31
Have you ever been diagnosed, treated, or self-identified with alcohol use disorder, drug addiction or any other substances or activities?
Question 28 of 31
Have you experienced what you would regard as a traumatic incident in your past that you would like us to know about?
Question 29 of 31
Do you currently work or are you interested in working as ceremony guide, guardian, trip sitter
If so, describe further below.
Question 30 of 31
Do you need a payment plan in order to commit to this journey?
Question 31 of 31
Anything else you’d like me to know about you?