Holistic Health Check

Oneness Meditation

I'm excited to get to know you better! This helps us create a safe, supportive space for your meditation program, where you'll be guided with care and understanding. It takes about 15 minutes to complete, and it’s a little easier on a laptop than a phone. Your responses are completely confidential. If you're on any medications or supplements, keep in mind that they can affect your experience, so please provide full and accurate details.

My Personal Details

First Name *

Last Name *

Phone *

Email *

City *

State *

Post Code *

Country *

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Date of birth *

Gender *

♀ Female
♂ Male
🏳️‍🌈 Other
No elements found. Consider changing the search query.
List is empty.

Job *

Languages *

Date & Location of your preferred Oneness event? *

Referrer First Name

Referrer Last Name

My Physical Wellbeing

How is your overall physical health? *

⭐️⭐️⭐️⭐️⭐️
⭐️⭐️⭐️⭐️
⭐️⭐️⭐️
⭐️⭐️
⭐️
No elements found. Consider changing the search query.
List is empty.

Have you ever been diagnosed with or think you might have any of these medical conditions? *

Select all that apply or 'none'

Asthma or COPD
Cancer
Chest pain or angina
Coronary Artery Disease
Diabetes
Epilepsy or Seizure Disorder
Heart Arrythmia
Heart Attack
Heart Failure
High Blood Pressure
Liver or Kidney Failure
Pregnancy (currently)
Stroke
None of these conditions
No elements found. Consider changing the search query.
List is empty.

Please provide a list of ALL medications that you are taking. Include the medication name, dose, reason for use, and how long you've been taking it. eg. Trazodone 50mg for sleep for 9 months, usually 3-5x/week *

Please provide a list of ALL supplements, over the counter, or herbal products you're taking. Include the name, dose, reason for use, and how long you've been using it. eg. St. John's Wort, 10mls, for sleep support for 5 months, about 4x/week *

Have you received a Covid19-related vaccine or booster within the last year? *

No
Yes
No elements found. Consider changing the search query.
List is empty.

Have you every been hospitalised or had surgery? If so, please describe event(s) & date(s). *

Have you ever had a head injury? If so, please describe event(s) & date(s). *

Please describe your diet in terms of what you eat in a typical day. *

On retreats we serve mostly plant-based, gluten-free, dairy-free meals to optimise your experience of purification and healing. Please advise of any food allergies or sensitivities. *

Do you use CAFFEINE products? If so, please describe what type, how much, and for how long. *

Do you drink ALCOHOL? If so, please describe what type, how much, and for how long. *

Do you use TOBACCO products? If so, please describe what type, how much, and for how long. *

Do you use CANNABIS products? If so, please describe what type, how much, and for how long. *

My Medicine Experience

Do you use or have you tried any non-psychedelic drugs? e.g. cocaine, methamphetamine, heroin, ketamine, etc. *

Yes
No
No elements found. Consider changing the search query.
List is empty.

If yes, please describe which non-psychedelic drugs, route of administration, how much and for how long

Do you use or have you tried any psychedelic substances? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

If yes, which have you experienced? Has it been in a recreational, psychonautic, ceremonial, therapeutic, or clinical context? Eg. LSD, many times recreational. MDMA therapy twice. Ayahuasca 3 times, ceremonial.

Have you ever had VERY difficult or challenging experience(s) with psychedelics or altered states? Please describe if so.

If you've had previous psychedelic experience please describe the impact this has had on your life.

My Mental Wellbeing

How would you rate your overall mental health? *

⭐️⭐️⭐️⭐️⭐️
⭐️⭐️⭐️⭐️
⭐️⭐️⭐️
⭐️⭐️
⭐️
No elements found. Consider changing the search query.
List is empty.

Which of the following conditions have you been diagnosed with or suspect you suffer from? Select all that apply or 'none' *

Select all that apply or 'none'

Anxiety
Bipolar Disorder
Depression
Obsessive Compulsive Disorder
Personality Disorder
PTSD
Schizophrenia or other Psychotic Disorder
Substance Use Disorder or Addiction
None
No elements found. Consider changing the search query.
List is empty.

Please describe any mental health struggles from the last question that you've had, or any others experienced. Include the date(s) & event(s) of any hospitalisation for a psychiatric reason.

Do you have a STRONG and/or FREQUENT experience with any of the following? *

Anxiety
Bad Temper
Depression
Dislike Critism
Easily Stressed
Feeling Lonely
Helpless Outlook
Nervousness
Poor Memory
None of the above
Other- please describe above
No elements found. Consider changing the search query.
List is empty.

Do you have any difficulty trusting others or life? How often do you experience fear or paranoia? *

Have you ever had thoughts of suicide or attempted to hurt yourself? If so, please describe event(s) and dates(s). *

Have you ever been physically, verbally, emotionally or sexually abused? At what age? If you are comfortable you may go into further details which will help us better understand and serve you. *

If there are any other significant trauma(s) you wish to describe, please do.

My Emotional Wellbeing

How would you rate your overall emotional health? *

⭐️⭐️⭐️⭐️⭐️
⭐️⭐️⭐️⭐️
⭐️⭐️⭐️
⭐️⭐️
⭐️
No elements found. Consider changing the search query.
List is empty.

What is your current living and social situation? Who do you live with? Do you have housemates, a partner, children, etc.? *

Please describe the quality of your interpersonal relationships and social interaction. Are there any ongoing struggles? *

What are your self-care practices? How do you nurture yourself? *

How do you typically cope with difficulty or adversity in your life? *

Do you have a preferred method of personal development, spiritual practice or discipline? If so, how would you describe it? *

Please describe your current professional/FORMAL SUPPORT network. (eg. psychologist, therapist, alternative medicine practitioner) How often do you see them? How readily available would they be if you needed support? *

Who else could you call and rely on to receive help and INFORMAL SUPPORT? Is there anyone else that you know and trust who you could speak specifically about this work with? *

What are their dispositions towards you doing this work? *

What practices do you feel will be most beneficial in helping you to integrate this experience into your life? And how will you put them to use? *

What do you know or have heard about this meditation? Do you have any concerns? *

My Intentions

What is your intention for your oneness meditation? *

What are the top 3 things that you're hoping you may gain from this program? *

What are the top 3 things you're hoping to let go of or leave behind by doing this program? *

Is there anything else you would like us to be aware of or any specific questions you have?

My Trusted People

We always strive to make sure you have a safe and positive experience, but there are some risks involved. It’s a good idea to have contact info for two trusted people, just in case you need help getting home or if an emergency comes up.

Trusted Person 1 *

Trusted Person 2 *

Terms & Conditions

I understand the importance of providing accurate info to ensure a safe and positive experience for myself. I recognise that being untruthful could affect my experience, and I’ve filled out this form honestly. I take responsibility for my health and acknowledge that participating in this program may come with some risks. To the best of my knowledge, I am in good physical condition and do not have any issues that would put me at risk.

In the unlikely event of a medical emergency, I will seek help right away and give permission for emergency services to be contacted. I’ll make sure to have the right support in place to get the most out of this program and reduce any risks.

By participating, I release and agree not to hold the program’s leaders, organisers, hosts, or fellow participants liable for any injuries or damages that might occur. I take full responsibility for any risks related to my participation, including any loss or damage to myself or my property.

I’ve read, understood, and agree to this form. I am an adult, at least 18 years old, and fully capable of making this decision. This waiver applies to all current and future activities with the program leader.

⬅ I've read and agree to the terms and conditions above

My Signature *

Clear

Today's Date *