Clare Patricia - Elemental Journey Application form

This application form is your first step to your journey through The 5 Elements.

Name

In one sentence, explain why you are being drawn to journey The Five Elements

What areas of your life do you most want to transform/improve?

What would be an outstanding outcome for you as a result of doing this program?

What would that give you?

Please list any and all mental health diagnoses you have been given.

Are you taking any prescription and/or over-the-counter medication? (Including medical & non-medical cannabis) If so, please list all medication, dosages, length of use, and reason/diagnosis for taking medication.

Have you recently done any plant medicine or do you have plans to take any plant medicine in the next 4 months? If so please list the type of medicine and date taken, as well as details about any of the processes that may be relevant for your practitioner to know. ***Please note your practitioner may ask you to abstain from all plant medicine for the duration of the process.

Do you drink alcohol or use drugs recreationally? If so please list drugs and amount and frequency of use. ***Please note your practitioner may ask you to abstain from all alcohol and drug use for the duration of the process.

Have you been through any major spiritual/personal development processes in the last year? If so please list what they were, the date you completed the process, who the facilitator was, and the outcome.

Are you ready and willing to commit yourself 100% to this process, complete the tasks assigned to you by your practitioner and follow the advice given to you throughout the process?

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