CACAOISTA TRAINING REGISTRATION FORM Name * First Name Last Name Email * Mobile Number * Country (###) ### #### Date of Birth * MM DD YYYY Emergency Contact, please include name, phone, e-mail, relationship to you and country of residence * To be able to facilitate with Cacao we expect a certain level of understanding about the nature of plant medicines. Please give a brief description of your history with ceremony, plant medicine? e.g have you attended ceremonies, how many? What is your relationship with the spirit of Cacao or any other plant medicine etc. * Have you ever facilitated a Cacao Ceremony? If so please give details... * Please share your healing intentions and why you are interested in coming on the retreat. * Do you have previous experience holding ceremonial space or workshops other than Cacao? * Have you recently sought out any counselling, psychiatric, or energy work? * Have you experienced trauma in your life? * Do you drink alcohol? (if yes, how often?) * Do you smoke? (if yes, how often?) * Do you use any other 'illegal' substance(s)? (if yes, which ones and how often?) * Are you taking ANY western medical prescriptions, over-the-counter, or alternative, homeopathic medications or taking herbal supplements? If so, please list them below and explain. * Do you suffer from high blood pressure? * Yes No Are you taking depression medication such as SSRI's? * Yes No Are you taking antidepressants such as MAO inhibitors? * Yes No Have you in the past or currently suffer from seizures? If YES, to any of the above please can give specifics.. e.g dosages/types/how long ago was your most recent seizure? * Do you have any dietary restrictions? This includes allergies, vegan/vegetarian, or gluten free…Please be specific. * Please share with us anything else we need to know that would make your stay more comfortable…. Is there anything else you would like us to know about yourself? Please be as specific as possible. This information is very helpful for our management team Do you agree with Rebekah's Terms & Conditions? * Please mark below if you agree with Rebekah's Terms & Conditions, and thank you so much for your honesty and understanding ♥ We are all really excited to be sharing Cacao and this journey with you! Yes - I agree : ) No - I do not agree : ( Thank you!
