Do you have any spiritual practices or beliefs (there is no "right" answer)?
What intentions are you bringing to ceremony? Please share anything you're ready to release—such as patterns, beliefs, or habits that no longer serve you—as well as what you're hoping to call in, embody, or create in your life moving forward.
Have you used plant medicines or psychedelics in the past? If yes, please specify which substances you have used and provide details, including any difficult or adverse reactions you experienced.
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Have you ever been in counseling?
If yes, for what issues?
Have you ever been diagnosed with any of the following?
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Please share any additional medical conditions and/or diseases that are not listed above. If none, please type N/A or none.
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Please list any medications, herbs, or recreational drugs you are currently using or have recently stopped using. For prescription medications, include dosage, frequency, and length of time on the medication. If none, please type ‘None.’
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Please list any allergens to medication or food.
I am voluntarily participating in a workshop/retreat facilitated by Julie Dunnwald and Keith Garde, which includes shamanic, yogic, meditative, and psychological exercises and practices intended to deepen self-awareness and support psychospiritual growth.
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I acknowledge that certain processes during the workshop/retreat may be physically, emotionally, or mentally demanding, and I accept full responsibility for safeguarding my health and well-being throughout the experience.
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I understand that using drugs or herbs may pose risks to my health and safety. If I need to discontinue any prescribed medication, I will do so safely and consult my physician as appropriate.
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I affirm that I have fully disclosed all medical and psychiatric conditions that could impact my ability to participate in the workshop or retreat, or that may pose a risk to myself or others, in this form.
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I affirm that I have completely and truthfully listed all antidepressants and mood-altering medications I am currently taking in this form.
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I acknowledge that the workshop/retreat is not intended as a treatment or therapy for any physical or psychological condition. If I require or desire medical or psychotherapeutic care, I will seek assistance from qualified professionals.
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I release and hold harmless the facilitators, Julie Dunnwald and Keith Garde, from any and all liability, loss, injury, or damage that may arise from or be related to my participation in the workshop/retreat.
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I agree not to pursue any form of litigation or legal action against the facilitators, Julie Dunnwald and Keith Garde, and instead commit to resolving any disputes or disagreements through direct dialogue or mediated negotiation.
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I confirm that the information provided in this form is accurate, complete, and submitted truthfully to the best of my knowledge and ability.
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I confirm that I am in a physical and emotional condition suitable for participating in the activities described as part of the ceremony. I understand and accept that I am participating at my own risk, and I agree that Soul Journey and its affiliates shall not be held liable for any accident, injury, or harm that may occur.
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By placing your initials here, you affirm that you have truthfully and fully disclosed all medications, substances (including drugs and herbs) you are currently using or have recently used, as well as any current or past medical or mental health conditions for which you have been diagnosed.
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I acknowledge that participation in the workshop or retreat involves inherent risks, some of which may be unpredictable and not related to my prior health history or experience. I understand that individual responses to the activities may vary and cannot be fully anticipated. Accordingly, I accept full responsibility for my health and safety and voluntarily assume all risks associated with my participation. I hereby waive, release, and discharge any and all claims for injury, damages, or loss that may arise from my participation—whether caused by negligence or otherwise—against the facilitators, staff, and all individuals or entities involved in organizing or supporting the workshop or retreat. This waiver extends to claims made on behalf of myself, my heirs, executors, and assigns. Additionally, I accept full responsibility for my conduct during the workshop or retreat, including all interactions with fellow participants, facilitators, and support personnel.
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