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SARAH LEMMERMAN M.A., IAKP, RYT
Masters Degree in East/West Psychology, Plant Medicine Researcher, Human Design Projector Guide, and Integrative Counselor
sarah.projectormovement@gmail.com
Health Questionnaire
Your name
Your email
Phone No.
Address
Date of Birth
How did you hear about this work?
What are some areas in your life that feel blocked or need improvement?
Are you pregnant or breastfeeding?
What ceremonial work, if any, have you done?
Do you have any current health challenges or medical concerns?
Do you have any past health challenges or medical concerns?
Have you been diagosed with any mental illness? If so, are you actively in therapy and/or taking prescription medications? Please list all below
Do you have allergies or sensitivities?
Are you in recovery from a major surgical procedure?
Kambo clients only - if not applicable please write N/A below. Do you have Diabetes, Kidney, Liver, or Addison's disease?
Kambo clients only - if not applicable please write N/A below.Do you have a history of heart disease, blood clots, or bypass surgery?
Have you been diagosed with any mental illness? If so, are you actively in therapy and/or taking prescription medications? Please list all below
Kambo clients only - if not applicable please write N/A below.Do you have high or low blood pressure? If so, do you take medication for your blood pressure
Kambo clients only - if not applicable please write N/A below.Do you have asthma or breathing problems?
Kambo clients only - if not applicable please write N/A below.Have you received chemotherapy or radiation within the last 8 weeks?
Kambo clients only - if not applicable please write N/A below.
Kambo clients only - if not applicable please write N/A below.Do you have any artificial devices in body such as a stint,brain devices, organ/stem cell, or breast implants?
Kambo clients only - if not applicable please write N/A below. Do you have varicose veins treated by medication?
Kambo clients only - if not applicable please write N/A below.Are you in advanced stage Lyme disease?
Kambo clients only - if not applicable please write N/A below.Have you recently worked with Iboga or Bufo(5-MEO)?
What is your occupation or what do you do for a living?
Kambo clients only - if not applicable please write N/A below.
Yes or No - I am of sound mind and body to make the decision to willingly participate in this healing ceremony?
Have you ever tried plant medicines like Ayahuasca, Iboga, Mushrooms, Sananga or Hape?
Any other information you would like Sarah to know?
Thanks! We will review your application and be in touch shortly!
Apply Now
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