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Noble Mountain Healing Intake Form

We’d Love to Hear From You

Image by JASMINE SATHIAGNANAN

Noble Mountain Healing Intake Form

Personal Information

Date of Birth
Month
Day
Year

General Health Information

Do you have asthma or severe allergies?
Yes
No
Do you have a history of fainting, seizures, or severe anxiety/panic attacks?
Yes
No
Are you pregnant or breastfeeding?
Yes
No

Experience With Indigenous Medicines

Have you previously worked with Bufo Alvarius?
Have you previously worked with Kambo?

Personal Intentions

Safey & Consent

I understand that Noble Mountain Healing is a Christian ministry
Yes
No
I understand that Bufo Alvarius and Kambo are used legally in the locations we serve.
yes
No
I understand these tools are not substitutes for medical or mental health treatment.
Yes
No
I understand my participation is voluntary and I may stop at any time.
Yes
No
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Logistics

Which retreat are you attending?

Donation & Tax Acknowledgement

I understand all contributions to Noble Mountain Healing / Casa de Vida Nueva are charitable donations and non-refundable.
Yes
No
I understand all donations and retreat contributions are 100% tax-deductible.
Yes
No
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