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Health and Safety Questionnaire

Questionnaire for Safe & Responsible Practice

Please take the time to reflect on and answer the questions below for us to discuss on our next call or meeting. Please be as forthright as possible as your answers will help ensure you have a safe and positive Practice. 
 
Regarding privacy, your responses are only accessible to Sacred Garden Community Facilitators and will only be read when it is directly relevant to facilitation. If you have any concerns, please feel free to email [email protected] before engaging the questionnaire.
 
Once you have completed this questionnaire, you may schedule an intake interview where you can ask any questions or voice any concerns you may have before your first formal Practice. We look forward to co-creating a positive life transforming experience with you!

Start

Important info before you begin...

This form asks one question at a time and does NOT allow you to go back and edit previous answers.

Please keep a pen and paper handy (or have digital note app) to jot down any additional info to answers that spring to mind while answering later questions.

There will be a place at the end to fill in any info you may remembered after the original question.

Question 2 of 44

Your Full Name

Question 3 of 44

Your phone number:

Question 4 of 44

Your Emergency Contact's Name

Question 5 of 44

Your Emergency Contact's Phone Number

Question 6 of 44

Is this emergency contact person aware of your SGC practice and can we identify ourselves if we need to call them?

A

Yes

B

No

Health Screening Questions

Before engaging in any form of deep meditation practice, please discuss any and all medications you are taking, and any illness with your facilitator.

Question 8 of 44

When was your last physical/wellness check-up?

Question 9 of 44

How old are you (in earth years)?

Question 10 of 44

How tall are you?

Question 11 of 44

How much do you currently weigh?

Question 12 of 44

Have you been medically diagnosed, have you experienced, or do you experience:

(Select all that apply)
A

Pre-existing cardio-vascular disease, stroke or aneurysm

B

Significant high blood-pressure

C

Respiratory disorders

D

Seizures or other neurological conditions

E

Significant allergies (food, environmental, drug - anything requiring medical intervention if exposed)

F

Currently Pregnant or Breastfeeding

G

Diabetes

H

Recent major surgery (requiring general anesthetic) or significant injury

I

Severe Liver or Kidney Disease

J

None of the above

K

Other

Question 13 of 44

If you answered "Other" or have significant allergies, please elaborate here:

Question 14 of 44

Are you affected by any of the following mental health concerns

(Select all that apply)
A

Depression

B

Bipolar disorder (also known as manic depression)

C

Anxiety

D

Post Traumatic Stress disorder (PTSD)

E

Obsessive Compulsive disorder (OCD)

F

Schizophrenia or Schizoaffective disorder

G

Social Anxiety disorder

H

Hospitalization within the past year for a mental health challenge

I

Other concern not listed here

J

None of the above

Question 15 of 44

If you answered "Other concern not listed" please elaborate here:

Question 16 of 44

Are you taking any prescribed psychiatric medication intended to shift your mood and/or brain chemistry?
Some major categories are described below

(Select all that apply)
A

Antidepressants: SSRIs, SNRIs, Tricyclics. Commonly prescribed for depression, anxiety, PTSD. Common medications include Prozac, Zoloft, Paxil, Lexapro, Effexor, Wellbutrin (also Zyban), Cymbalta, Parnate, Elavil.

B

MAOI (monoamine oxidase inhibitors) Common names include Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)

C

Anti-Anxiety Agents: Benzodiazepines. Commonly prescribed for anxiety and panic attacks. Common medications include Valium, Xanax, Klonopin, Ativan.

D

Stimulants: Commonly prescribed for ADHD. Common medications include Ritalin, Adderal, Vyvanse, Dexadrine, Concerta.

E

Antipsychotics: Commonly prescribed for schizophrenia, sometimes prescribed for significant anxiety, depression, PTSD, bipolar disorder, sleep difficulties. Common medications include Haldol, Zyprexa, Risperdal, Seroquel, Geodon, Abilify.

F

Mood Stabilizers: Commonly prescribed for bipolar disorder (manic depression). Sometimes prescribed for depression, epilepsy. Common medications include Lithium, Depakote, Lamictal.

G

Other prescribed medication that has an impact on mood and/or brain chemistry

H

None of the above

Question 17 of 44

If you answered "Other prescribed medication that has an impact on mood and/or brain chemistry" please list it/them here:

Question 18 of 44

Absolute Contraindications (for certain liturgies)

Are you currently taking any of the following medications:

(Select all that apply)
A

MAOI's (monoamine oxidase inhibitors) Common names include Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate)

B

HIV/AIDS meds such as ritonavir or cobicistat

C

Bupropion (Wellbutrin)

D

Fluconazole (Diflucan)

E

Lithium

F

None of the above

Question 19 of 44

Cautionary medication information, if you are taking any of the following medications please discuss with your intake person. For certain liturgies these drugs can shorten time of onset and increase peak blood level.

(Select all that apply)
A

Cimetidine (Tagamet)

B

Fluoxetine (Prozac)

C

Paroxetine (Paxil)

D

Fluconazole (antifungal)

E

None of the above

Question 20 of 44

Please list all medications, supplements and drugs you are currently using, including the dose and frequency.
This information will be kept under [Pastoral] confidentiality and may be shared with ordained facilitators and  SGC's medical support team.

Experience

We would like to know a bit your experience with the Sacraments of our church  

Question 22 of 44

Have you experienced a session with entheogens before?

A

Yes

B

No

Question 23 of 44

If so, how long have you been working with entheogens for?

Question 24 of 44

If you have had experience with entheogens before, what  Sacrament(s) /  material(s) have you had experience with?

Question 25 of 44

If you have had experience with entheogens before, roughly how long ago was your most recent experience?

Question 26 of 44

If you have had experience with entheogens before, what was the experience like for you?

Personal Questions

Although some emotional concerns may be benefited by participation, considerations in participating must be made on a case-by-case basis. All mental health concerns should be clearly and openly communicated with the prospective Facilitator as part of the health screening process. Please note that we are not medical or mental health practitioners and this is not medical or mental health care. Your full and open participation in the consideration process will support you in having a more positive experience. And your full honesty will cultivate a rapport full of trust, care, and respect with your facilitator. While it may not be appropriate for every Practitioner to engage with every sacrament, SGC will always work with you to find the most appropriate spiritual care.

Question 28 of 44

What are your reasons for wanting to do this work?

Question 29 of 44

Please describe any traumatic events in your life that you feel comfortable with sharing. If you don't feel comfortable sharing via this form (but do have trauma that feel relevant), please indicate that you would prefer to be asked about this in person. 

Question 30 of 44

Are you facing any strong or persisting fears in your life?

Question 31 of 44

Are you currently experiencing any unusual stress, overwhelm, or challenges you're struggling to manage? 
Please describe.

Question 32 of 44

What support systems, in terms of resources and relationships (family, friends, co-workers, other church, mosque, temple, therapists, or spiritual teachers) do you have in place that can be of support after deep meditation?

Question 33 of 44

Do you currently have a personal spiritual/self-care practice that includes meditation or mindfulness practices? 
Please describe.

Question 34 of 44

Please briefly describe ways you've practiced and/or studied religious and/or spiritual paths. 
Teachers, level of participation, books read, etc.

Question 35 of 44

Is there anything you would like to share about your identities (racial, gender, sexual, cultural, etc.) and/or any hopes or concerns you have related to how we can make Sacred Garden Community a more safe and welcoming space for you?

Question 36 of 44

We recognize that sometimes people are drawn to this work because they are wrestling with existential issues. At the same part time of SGC's careful practice involves finding out more about your experience.

(Select all that apply)
A

Have you wished you were dead or wished you could go to sleep and not wake up in the past month?

B

Have you had any thoughts about killing yourself in the past month?

C

Have you attempted suicide within the last year?

D

None of the above

Consent

For each sacrament practice we create a "container" that is held loving by our intentions and agreements. Different liturgies (with different sacraments) will have different intentions, and different agreements around welcomed behaviors. Some may require silence throughout the practice, while others will welcome sound and singing. One very significant dimension of these agreements is around touch, energy exchange, sensuality, and sexuality. All SGC sacrament practices are within a strictly Platonic container meaning non-sexual, non-romantic (your facilitator will explain more about what this means during your preparation.)

AND... There may be circumstances during ceremony when a facilitator needs to touch you in order to keep you and/or other practitioners safe from harm, regardless of your level of comfort with uninvited touch. 

If you become disruptive or unsafe in ceremony a facilitator may make the judgment call to use touch to keep you and others safe from harm. In such an event, we will be kind, careful, and respectful.

 
In order to be as careful and respectful as possible we would like to know about your comfort level and preferences regarding touch.  
 
Please note that this is just the beginning of an ongoing conversation about consent, as true consent is not a static once and done declaration, it is a dynamic process that you have agency to direct in each and every moment. While our facilitators will always do their best to honor your preferences, simply stating them on this form is insufficient. It’s your responsibility to make sure your preferences around touch are explicitly clear to your facilitator before every ceremony.
 

Question 38 of 44

Do you agree to follow the guidance of your facilitator when it comes to upholding the agreements of the sacramental containers in which you practice with SGC? (ie. If the facilitator tells us this is a no touch ceremony I agree not to touch.)

A

I agree and understand that if I do not uphold the agreements, the facilitator will call attention to my behaviors and may need to redirect me

B

I do not understand the question well enough to agree to it

C

I don't believe I can be held accountable for my behaviors while I am under the influence of certain sacraments

Question 39 of 44

What are your preferences regarding touch (non-sexual)? When interacting with people that you don't have any prearranged consent around touch would you prefer:

A

Green – You can touch me (non-sexually) without asking and I will let you know if I don’t like the way you are touching me.

B

Yellow – You can offer me touch beyond what's needed to keep and other physically safe, and I will let you know if it’s ok.

C

Red – Do not ever touch (or offer me touch) me unless its a matter of safety. If I want touch, I will initiate that conversation.

D

Blue – Good question! I’m not entirely sure what my preferences around touch are, please talk to me about this.

E

I don't understand enough about this question and the nature of the practices to answer in good faith, please talk to me about it more

F

Consent is more complex than a color, I'll discuss this with my facilitator

Question 40 of 44

As noted above there may be times when a facilitator has to touch you as a means of keeping yourself and/or other practitioners safe from harm, regardless of your stated boundaries. If you become disruptive or unsafe in ceremony a facilitator may make the judgment call to use touch to keep you and others safe from harm. It is rare this happens, and in case it does...
 
If you are not a "green" can you be explicit in how to deal with touching you for safety reasons? (ie, if possible, approach me from the front, not the side or behind, and if possible make eye contact with me, and narrate what you are about to do and why, like "I'm concerned you are going to fall and hurt yourself, so I'm going to move to your side and put my arm around you to keep you from falling)

Question 41 of 44

Sometimes we have strong experiences that may overwhelm our ability to remember the behavioral agreements of the container and/or result in behavior that is disruptive to other practitioners' experiences. If this happens in ceremony a facilitator may make the judgment call to redirect you.
 
Can you provide us with guidance on how to interact with you if you become disruptive in ceremony? (ie. verbally remind me to breathe and find my center) 

Rupture & Repair

Again, we want to remind you that consent is an ongoing conversation, it is not a static, once and done declaration. It is a dynamic process that you have agency to direct in each and every moment. It is your responsibility to make sure your preferences around touch are explicitly clear to your facilitator before every ceremony. And if anything ever does not feel right in the moment, we encourage you to use immediacy and address it in the moment.

In the event that something you find offensive or in violation of your safety happens, that you were not able to address in the moment, please take note of SGC's Creating Safety Framework for resolving problems (if you wish to read / bookmark this now, PLEASE open it in a separate tab or window so you do not lose the answers you've filled in so far): https://drive.google.com/file/d/1hRfIuZToIcN_3GY3n74NRhP58FQEzPXp/view

If it feels significantly harmful or if you need help resolving it, please consider making a report to SGC's Ethics Council (if you wish to read / bookmark this now, PLEASE open it in a separate tab or window so you do not lose the answers you've filled in so far): https://drive.google.com/file/d/103LsfZVDAm0FlhdnoG8omuM_1ZeQCTf0/view

Question 43 of 44

Do you have any other questions, comments, and/or concerns you'd like to voice?

Question 44 of 44

As mentioned before, this form does not allow you to go back and edit previous answers. If any additional info sprung to mind while answering later questions, after you submitted the answer to the original question, please make a note of it here.

Confirm and Submit