Yaou Yaou Wellness
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Appointment
Appointment Form
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Email
(Required)
Name Of Participant
(Required)
First
Phone Number Of Participant
(Required)
Which offering would you like to learn more about?
(Required)
Iboga Bwiti Retreats
Kambo Treatments
Cacao and Hibiscus Healing Circles
1:1 Afro-Indigenous Coaching and Consulting
Group Afro-Indigenous Coaching and Consulting
Select All
Have you had a liver panel recently or in the past? If yes, when and what were the results?
Have you had an EKG (electrocardiogram) test done? If yes, when and what were the results?
Please check the box if the answer is "Yes":
(Required)
Are you pregnant?
Have you ever suffered from a heart condition?
Have you ever suffered from a liver condition?
Have you been hospitalized in the last 20 years?
Have you ever been hospitalized for a psychiatric illness?
Is there anyone in your family with a history of psychiatric disorders?
Are you currently receiving therapy or attending any kind of support group?
N/A
Select All
Medical Diagnosis - Please list all medical diagnosis, past and current, with dates.
Medications and Supplements - Please list all medications, prescribed or otherwise, and supplements. Please include dosage and frequency.
Do you currently experience addiction to any drugs, or have you in the past? If so, please describe what & frequency/dosage.
Are you addicted to alcohol, or have you been in the past? if so, please describe.
Do you now or have you had a problem with any of the following? Check all that apply.
(Required)
Cannabis
Internet / Social Media
Cigarettes
Exercise
Coffee
Shopping
TV
Food
Sex
Pornography
Prescription Medication
Drugs
None of the above
Select All
Describe your relationship to food. Please be specific. *
Do you now or in the past experience any of the following?
(Required)
Dislike your body shape or size?
Fear of certain foods or preoccupation with food causing illness?
Overeating then purging by vomiting?
Eating or overeating when emotional?
Stopped eating or deprived yourself of food?
Ever been diagnosed or treated for an eating disorder?
None of the above
Select All
How well do you sleep? Do you feel rested upon rising? Please be specific. *
Where are your parents from? What is your relationship with them? Please be specific.
Whats your current relationship with your siblings? Please be specific. *
Is there anything else about your physical or emotional state we should know about? ("N/A" if does not apply)
Marital/relationship status. Please be specific. *
Do you have children? Do they live with you? Please be specific. *
Whats your current relationship with friends? Please be specific. *
What are current stressors in your life? *
What do you do for fun? *
Have you experienced any of the following? *
(Required)
Combat/war
Being held hostage or imprisoned
Terrorism or hate crime
Natural or man-made disaster
Accidents
Diagnosis of life threatening illness
Sexual abuse
Physical abuse
Torture
None of the above
Select All
Please elaborate on any above checked items.
Have you experienced any of the following losses? *
(Required)
Deaths
Pregnancy
Relationships
Jobs
Culture
None of the above
Select All
Please elaborate on any above checked items
Do you engage in any of the following forms of self harm? *
(Required)
Cutting
Inserting sharp objects into the skin
Biting
Swallowing sharp objects or hamful substances
Scratching
Scraping
Picking
Pulling out hair
None of the above
Select All
Please elaborate on any above checked items.
Have you taken any indigenous plant or animal medicines before? If so, please list them below. ("N/A" if does not apply)
What is your current diet? Do you have any dietary restrictions or food you avoid? (i.e. lactose intolerance, gluten sensitivity)
Have you ever had thoughts of hurting yourself or another? When was the last time?
Do you ever have hallucinations? Paranoid thoughts? Hear voices? Memory loss?
Do you experience fears or phobias that interfere with day to day living? If so, what?
Do you experience any sexual disfunction? i.e. lack of ability or interest in sex? *
What are the reasons you're seeking natural medicine at this time in your life? *
Please list the name and number of at least one (1) emergency contact: *
I understand that I will have to submit an EKG and a metabolic panel to be medically cleared for Traditional Bwiti Treatments.
Yes
I understand that I must have completed my cash payment 2 days before the treatment date.
Yes
I declare that I have read and understood the information in this form. I further declare that I have answered all the above questions fully and honestly and have not withheld any information that I believe could be important. As far as I am aware, my general health is good.
Yes
I acknowledge that I have been told of the possible risks of natural medicine modalities, and I have been given satisfactory answers to my questions concerning any and all procedures and related matters without prejudice. Therefore, I indemnify and hold harmless Yaou Yaou Wellness and supporting staff against any and all liability in any way connected to my participation in indigenous natural medicine treatments.
Yes
I am an adult, aged 21 or older, legally and mentally competent to make informed decisions regarding my sincerely held religious beliefs, health, and wellbeing.
Yes
I acknowledge that I am participating in a sacred ceremony solely on my own behalf and not as an agent of any governing body or government-affiliated agency.
Yes
Home
About Us
About Us
Family
Reviews
Offerings
Offerings
Coaching and Consulting
Iboga
Kambô
Cacao
Shop
Resources
Contact
Home
About Us
About Us
Family
Reviews
Offerings
Offerings
Coaching and Consulting
Iboga
Kambô
Cacao
Shop
Resources
Contact
Start Your Journey
