Intake Form - Shangriballa

Please complete the form below with as much information as possible, making sure your email address is correct. I will then send you more information about your treatments and retreat.

Kambo, Toad, and Plant Medicines are generally safe to use with a trained facilitator; however, they are not for everyone. At Shangriballa, we carefully screen each person to ensure their suitability for the retreat. You must disclose all the information on the “Client Intake Form.” We work with clients who are not suitable at the time of booking and, wherever possible, prepare them for a later date.

If you have or have ever had a medical condition, please check with your healthcare provider before attending any of our retreats. We are always happy to talk to you, so please reach out if you are unsure.

The intake form must be completed only by the person participating in the retreat; submissions from third parties, family, or friends will be rejected. (See our Terms and Conditions)

The form you complete will not be printed and stored. We will not keep a digital record of your form for longer than six months. You can request that the form be removed at any time after your retreat unless we need to keep this record for the specified six months in case of a dispute.

Please ensure you read our safety guides below before completing the form.
If You Lie, You Might Die

BUFO SAFETY

KAMBO SAFETY

Your information is safe on this website and will never be shared

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone

Mobile / Cell Phone Number *

Gender *

Age *

Emergency Contact *

First

Last

In the rare event that we need to contact family or a friend.

Emergency Contact Phone *

Please confirm you will have Travel Insurance *

Yes
No
Not Applicable

Please make sure you have travel and medical cover if needed.

Kambo Experience *

First Time
1-3
4+

Bufo Experience *

First Time
1-3
4+
Rather Not Say

Have You Taken Psychedelics Before *

Yes
No
Rather Not Say

This will help us to work out optimal dosages for you.

Diet - Are You? *

Vegan
Vegeterian
Omnivore
Pescetarian

Do you have food allergies or intolerances? *

Are You Allergic To Latex? *

Have you been diagnosed with any Medical Conditions? *

No
Yes
Under Investigation

Are you taking any Medication? *

Dont Include Vitamins & Supliments Here.

Have you taken any Medications in the last year? *

Some medicines take a long time to work out of the body and we need to make sure you are ready. Dont Include Vitamins & Supliments.

Are you taking Vitamins & Supplements? *

Have you ever been diagnosed with any Psychological condition? *

No
Yes
Under Investigation

Depression and Anxiety Included. This does not mean we cant work with you but need to know for our screening process.

Please list all Psychological conditions and medications.

Do you have a family history of any Psychological condition? *

No
Yes
Under Investigation

Please indicate family history so we can work out dosages for you accordingly.

Have you experienced a serious psychological episode (e.g. nervous breakdown, psychosis) in the last 12 months? *

No
Yes
Not sure

Please explain any breakdowns you had in the last 12 months?

Are you working with a therapist at the moment? *

Do you have any phobias? *

Have you ever had a stroke? *

Do you have low blood pressure? *

Do you have high blood pressure? *

Do you or have you ever suffered any heart conditions? *

No
Yes
Under Investigation

List any heart problems, conditions & investigations?

Please include any previous heart conditions surgery and investigations.

Have you ever had a brain injury? *

No
Yes
Not Sure

Please include concussions.

Please list brain injuries or concussions details and dates.

Have you ever had any surgery? *

What are you hoping to get out of your Retreat? (Your Intention) *

This information is strictly private so please open your heart so we know how to help you.

Any other information you want to share?

For Retreats - Are you interested in our Shuttle Service from Porto Airport? *

Yes
No
Not Sure

The cost of the shuttle is shared by participants, the final cost depends on the amount of people joining, usually between 30-50 Euros.

I agree to the Terms & Conditions of Shangriballa *

Terms & Conditions: https://shangriballa.com/index.php/terms-conditions/

Disclaimer. *

I understand and acknowledge the following:No Medical Services: Lisa & Miguel Silva and Shangriballa practitioners are not medical doctors or any other licensed healthcare professional. They do not diagnose diseases, offer medical advice, treat physical or mental health conditions, or prescribe medications or pharmaceuticals. Not a Substitute for Medical Care: Any complementary therapy or treatment provided by Shangriballa practitioners is not a substitute for a medical or psychological diagnosis or treatment by a qualified healthcare professional. You should always consult with a qualified healthcare professional for any physical or mental health conditions, including any new or existing conditions. Known Risks: I am aware of the potential risks associated with Kambo and other psychedelic substances, including but not limited to Boerhaave Syndrome (esophagus rupture) and other potential side effects. Safe Space, Not Suppliers: Shangriballa, Lisa & Miguel Silva do not produce, manufacture, sell, or distribute any psychedelic substances. They solely provide a safe and supportive space for individuals to engage in their chosen modalities using substances they have obtained elsewhere. Responsibility for Substances: I understand that I am solely responsible for obtaining and ensuring the quality and legality of any psychedelic substances I choose to use. Shangriballa, Lisa & Miguel Silva assume no responsibility for the source, quality, or legality of any substances used during participation in their services. Accuracy of Information: I confirm that all information I have provided to Shangriballa practitioners is accurate and complete. Release of Liability: I hereby release Lisa & Miguel Silva and Shangriballa practitioners from all liability arising from my participation in any therapy or treatment, including any use of equipment, materials, preparations, remedies, or treatments. I take full responsibility for all risks associated with my participation in any psychedelic experience, including any risks arising from the substances I have obtained and used. Information Sharing: I agree to allow Shangriballa practitioners to share my information with a licensed therapist if deemed necessary for screening or treatment purposes. Eligibility: I confirm that I am of legal age to consent to this disclaimer and that I fully understand the terms and conditions set forth herein. I confirm that I am the person applying to partake in your retreat. By signing this disclaimer, you acknowledge and agree to the terms and conditions set forth above.