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Terms & Privacy

Declaration of Self-Sovereignty

Disclaimer Agreement: By participating in this Amanita ceremonial offering, I hearby take full responsibility for ALL my choices I make that may affect my overall health & wellness. I declare myself to be sound in mind, body, heart and spirit and have the necessary supports in my life to assist my integration process, knowing that by partaking in this ceremony I may uncover aspects of myself- physically/emotionally/mentally/spiritually that may require further support after the ceremony is over. I am a free sovereign being that is freely capable of making responsible choices for myself. By completing this form and attending this ceremonial gathering, I am agreeing to take full responsibility for ALL my choices & actions and do not hold anyone but myself accountable for ANY & ALL occurrences that may cause ANY disturbances to my health & wellness (physically/emotionally/mentally/spiritually). I understand that this offering doesn’t provide medical advice and if I am concerned about taking Amanita and how this may affect my current health and some of the current medications I am taking, I am responsible for seeking my own medical advice. I agree to only participate to the capacity in which I can safely do so, honouring what my body, mind, heart & spirit are asking of me. I know myself best. And so it is.

Contraindications: (from B. Masha, Microdosing with Amanita Muscaria)

1. Mental illness (bipolar disorder, schizophrenia, cycles of mania and so on).

2. Pregnant mothers and those nursing newborns.

3. Presence of urolithiasis (kidney stones). Amanita activates the removal of stones from the bladder and kidneys.

Full Name

Date of Ceremony Attending (eg. 6/14/25)

What experience do you have with ingesting entheogens?

(Types of entheogens? Ceremonially, party environments, festivals, microdosing protocols, courses, clinically?)

Have you worked with Amanita Muscaria before?

Yes

What do you want to learn about Amanita by partaking in this offering?

What experience do you have with Conscious Connected Breathwork? Or any other breathwork practices?

Do you have a daily breathwork practice?

Yes

Sort Of...

Other

How would you describe your overall Mental, Emotional, Physical & Spiritual Health?

What area(s) of life at the moment are you desiring the most transformation/healing/clarity? Why?

What supportive tools do you utilize for moving through big energetic shifts in life? Integration practices? Healthy daily habits?

Please list and describe any current or past health conditions that may be applicable:

(eg. Physical/Mental/Emotional/Spiritual)

List any medications for past or current health conditions you have or are taking, if applicable:

Please list all recreational substances you have taken in the past or/and are currently taking. Also indicate any current or past substance abuse issues.

Prior to arriving at this ceremony, it is your responsibility as a participant to read the extra information sent to you, and if you have any questions, concerns, fears, worries etc... to ask them before your arrival. Do you agree?

Yes

Other

After the ceremony, it is your responsibility to create the necessary time & space for integration to occur. Which may include, reaching out for more support if needed by someone you can trust to hold space for what you’re moving through. Do you agree?

Yes

*All information here will be held strictly confidential. If attending another offering in the future, you will be asked to complete another intake form to ensure everything is updated for where you are at presently.

**I agree to honour this intake process, by taking the time & space to thoughtfully complete this form with the utmost honesty, honouring the integrity of this kind of transformational offering.

I confirm all details here to be true and accurate.