Immersion Application formTo participate in our immersions, please complete our Intake Form to ensure your understanding of our services and help us better meet your needs. Personal Information Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Date of Birth Emergency Contact Name Phone (###) ### #### General Questions How did you hear about Eco Tribal Immersions? Social Media Word of Mouth / Friend or Family Online Advertisement Event or Trade Show Podcast Google Search Other Have you ever participated in a tribal immersion or similar experience? Yes No Why are you interested in participating in a tribal immersion with Eco Tribal Immersions? What are your intentions for participating in this experience (spiritual, personal growth, healing, etc.)? Have you ever participated in humanitarian work before? Yes No Why do you feel that you can be a good participant in this type of tribal immersion? Plant Medicine Experience 1. Have you ever worked with any plant medicines? If yes, please list the plant medicines you have worked with: Yes No 2. If you have worked with plant medicines, how was the experience and when did it occur? Please describe the most notable effects, insights, or transformations you experienced: 3. Have you worked with Kambo before? If yes, please list the plant medicines you have worked with: Yes No Spiritual Development and Inner Work 1. Where do you currently stand in your spiritual development or practice? Just beginnin Intermediate Advanced 2. What types of inner work have you been focusing on? Meditation Breathwork Shadow work Personal healing Other 3. What are your intentions for joining this tribal immersion experience? Healing Spiritual growth Connection with nature Community building Other 4. How do you feel this type of tribal immersion can support your personal or spiritual growth? 5. Do you have any specific areas of personal or spiritual development you would like to focus on during this immersion? Health and Medical Information 1. Do you have any autoimmune diseases or conditions? Yes No 2. Do you have any history of endocrine disorders, such as Addison's Disease or other hormone imbalances? Yes No 3. Do you currently have any health problems? Yes No 4. Have you suffered from any significant health problems in the past or have you had any surgeries? Yes No 5. Do you have any history of mental health issues? (e.g., depression, anxiety, PTSD) Yes No 6. Do you take any prescribed medications, supplements, or herbs? Yes No 7. Are you currently taking any medications or treatments for chronic conditions? (e.g., high blood pressure, diabetes, etc.) Yes No 8. Do you have any allergies to medications, foods, or other substances? Yes No 9. Are you currently pregnant or breastfeeding? Yes No 10. Have you ever been diagnosed with or treated for any of the following conditions? (Check all that apply) Stroke Heart disease or conditions High blood pressure Diabetes Epilepsy or seizures Autoimmune disorders Mental health disorders Cancer Blood clots Other chronic conditions Lifestyle & Wellness 1. On average, how many glasses of water do you drink per day? None 1-2 3-5 6-8 9-11 12+ 2. Do you engage in regular physical exercise or activities? Yes No 3. Do you currently follow a particular diet or nutrition plan? Yes No 4. Do you have any habits that may impact your health or well-being? (e.g., smoking, alcohol consumption, etc.) Yes No Consent & Acknowledgements I acknowledge that I have answered all questions truthfully and to the best of my knowledge. I understand that failure to disclose important health information could result in complications during my participation in Eco Tribal Immersions. Yes No I consent to share my health information with Eco Tribal Immersions for the purpose of creating a safe immersions. I also acknowledge that it is my responsibility to inform Eco Tribal Immersions of any health changes that may affect my participation. Yes No Thank you!
