EARTH MEDICINE JOURNEY

Name

First Name

Last Name

Phone

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Emergency Contact (Name, Relationship, Phone)

HEALTH + MEDICAL HISTORY: (To ensure your safety during our session) Are you currently under the care of a physician or therapist? If yes, please explain. Please list any current or past medical conditions (e.g., heart issues, seizures, diabetes, etc.) Please list all current medications, including antidepressants, anti-anxiety meds, sleep aids, or supplements. (Important: SSRIs, SNRIs, MAOIs, benzodiazepines, and certain other medications can interact with psilocybin.) Any history of psychiatric diagnosis (e.g., bipolar, schizophrenia, PTSD, depression, anxiety)? Any hospitalizations for mental health reasons? If yes, please share when and for what reason. Are you pregnant, breastfeeding, or trying to conceive? Any known allergies (food, plant, or medication)?

PSYCHOLOGICAL + ENERGETIC HISTORY: Have you ever used psychedelics before? If yes, which and how recently? What has been your experience with those medicines (positive, challenging, neutral)? Are you currently experiencing heightened anxiety, panic, or depression? Any current major life stressors, grief, or trauma? Do you have a support system (friends, therapist, mentor, etc.) for post-journey integration?

INTENTIONS + READINESS: What draws you to explore this medicine journey? What would you like to explore, release, or receive clarity on? What outcomes or feelings would you love to embody after the session? Do you have any fears, hesitations, or boundaries you'd like to name beforehand?

CONTRAINDICATIONS SCREENING: Please confirm that you: Have not taken SSRIs, SNRIs, MAOIs, antipsychotics, or lithium within the past 30 days. Do not have a personal or family history of psychosis or schizophrenia. Have not consumed alcohol, cannabis, or other substances within 24–48 hours of the session. Are emotionally stable enough to engage in introspective or somatic healing work at this time.

AGREE

LOGISTICS + SAFETY AGREEMENT: Do you consent to participate in a guided somatic and breathwork-supported microdosing session? Do you understand this session is not a replacement for medical or psychiatric care? Do you consent to disclose any changes to your health or medications before the session? Do you give permission to contact your emergency contact in case of medical need?

AGREE

Disclaimer: By participating in this session, you acknowledge that you are engaging in a personal healing experience facilitated through somatic and breath-work practices combined with a guided journey. I am not a licensed medical doctor, psychiatrist, or psychologist, and this work is not intended to diagnose, treat, or replace professional medical or mental health care. You are solely responsible for your physical, emotional, and mental well-being before, during, and after the session. You agree to take full responsibility for your own health and outcomes related to this experience, and release the facilitator from any liability that may arise in connection with your participation.

Certifications:

Certified in Somatic Attachment Therapy

EMDR Therapy Certification For Trauma & PTSD

Certified Trauma Informed Coach

Re-patterning the Nervous System with Regulation Tools

Inner Bonding with Dr Margaret Paul [Healing Self Abandonment]

Creating Conscious Love with Sheleana Aiyana

Somatic Experiments for Attachment Healing

Catalyzing Safety & Connection in Intimate Relationships

Trans-generational Trauma and Attachment

Shadow Work in Relationships as Mirrors

An Ecology of Relationship: Exploring Connection, Belonging, Dignity & Shame

Specializing in Attachment Theory

Fertility Awareness

RYS300 Yoga Teacher Training

EAC Transformation Workshop Group Training Facilitator

Reiki Level 1 & 2 Certified

Somatic Psychedelic Facilitator Certification in progress

Pricing & Timeline

The session fee is $350 and sessions are held in person in Los Angeles. Each journey typically lasts between 2 to 4 hours, depending on the flow and depth of the experience. Please note that this fee does not include the post-session integration check-in, which is a separate and essential follow-up offered within 72 hours after your session to support grounding, emotional processing, and integration of your experience.