Application for Awethentic Journeys

Welcome. We are so humbled to be a part of your healing and growth journey in deep community. Please carve out around 15-20 minutes to complete these questions. Please know that your answers are completely confidential and are only seen by Jenna, Avi & our MD on staff. Afterwards a practitioner will reach out to schedule a consultation for next steps.

Name

First Name

Last Name

Date of birth

YYYY

Phone Number

Are you experiencing any injuries, pain, tension, or frustrations with your body?

Do you have the resources to pull together to invest in yourself (time-wise and financially) if you are a good fit for this program?

Do you have any current medical conditions?* If yes, please specify.

Are you currently taking any medications?* .

If yes, please list them

Do you have any allergies?

If yes, please specify.

Have you ever been diagnosed with a mental health condition?*

If yes, please provide details.

Do you have experience with plant medicine?

(micro or macro doses)

Have you experienced any major traumas in your life?

If yes, please describe.

Have you ever been hospitalized for a psychiatric condition?

If yes, please provide details.

Do you have a history of substance abuse?

* If yes, please describe.

Do you have any dietary restrictions?

Is there anything any addition information you'd like to share with us?

How did you hear about this program?

What are you hoping to transform?

What is motivating you to join this cohort container?

Awethentic Roots