a grounded, nature centered, faith based organization

ECLECTIC CENTER

ABASSA SOMATREE

SUPPORT & ENJOY OUR TEMPLE HERE

PLEASE answer all questions AS FULLY as possible for safety purposes. All information is STRICTLY CONFIDENTIAL.

Full name*

Birthday*

E-mail*

Phone number*

Do you use any of those apps?*

Signal app

None

Please tell us the name of the person who connected you to us. Check with your friend if they told us you will be contacting us. They MUST contact us before you fill out this form to be accepted.*

Have you been in this specific type of ceremonial retreat before?*

Yes

What date are you coming to the ceremonial retreat?*

We really appreciate your donation to cover the expenses and affords necessary to make the retreat happened. Any extra donation is always welcome. Please ask your receipt.*

Thank you

Are you coming to the ceremonial retreat to overcome alcoholism, any drug addiction, or a specific personal trauma? If the answer is YES, we would like to learn more about it on our call interview.*

Yes

Are you currently taking any kind of medication including antidepressants? IT IS ABSOLUTELY IMPORTANT to list all of them explaining what each*

Are you currently taking any kind of supplements, herbs etc? Please list all of them.*

Have you ever had a serious illness such as: cardiovascular disease including any heart-related issues, high blood pressure, contagious diseases, glaucoma, epilepsy, asthma or another health conditions?*

Do you have any allergies? Are you allergic to cats? Please explain how severe has been your allergies and what medications help you.*

Are you currently on any alternative treatment, detox, etc? Can you describe it?*

Have you ever had a surgery? What for? How long ago?*

Do you drink ALCOHOL? How often? IT IS ABSOLUTELY NECESSARY to let us know if you have an alcoholic habitat for your own safety.*

Are you trying to quit smoking TOBACCO?*

Have you ever suffered or are you currently suffering any psychiatric disorder? Can you describe it? Have you ever been admitted to a psychiatric clinic?*

Are you part of any religion or spiritual path? Can you briefly describe it?*

What date is today?*