Contact us

Participant Information

YesNo
Would you like to be added to our email list?

Address

--- Select Country ---United StatesCanadaUnited KingdomAustraliaOther

How did you hear about Ritual Church?

FacebookInstagramWebsiteParticipant Referral

Previous Experience

Have you ever attended a Breathwork ceremony with Ritual Church before?
YesNo

Have you ever attended a private ceremony with Ritual Church?
YesNo

Are you interested in a private session or group ceremony?
Private SessionGroup Ceremony

Please briefly state your reasons for seeking to attend a sacred healing ceremony with Ritual Church

What are your current life challenges?

Are there any trauma triggers that you would like us to be aware of (such as; touching, loud noises, tight spaces, shouting, drumming, high pitched noises or others)?
YesNo

Have you ever attended a Breathwork ceremony before? DMT; Psilocybin; Blue Lotus ceremony
YesNo

What would you like to gain from this experience?

What is your occupation?

What are your hobbies/interests?

Who are the most important people in your support network (friends, family, spiritual leaders or community, therapists, etc)?

Is there any area where your support network is lacking?
YesNo

In what time frame are you looking to attend ceremony?
Immediately1-3 Months3-6 MonthsMore than 6 Months

Have you ever experienced any of the following:

Meditation, consciousness-altering states, or shamanic retreats?
YesNo

Trauma in CHILDHOOD?
YesNo

Trauma in ADULTHOOD?
YesNo

Significant losses or grief?
YesNo

Does your immediate family support your having this experience?
YesNo

Are you serving or have you served in any branch of the armed forces of the United States?
YesNo

Are you currently or have you ever been a first responder (peace officer, highway patrol, firefighter, EMT, paramedic, emergency room medical staff, disaster relief worker, social worker, public safety dispatcher)
YesNo

Questions and Concerns