Client Form

$250 Private (One-on-one)
$200 Semi-Private (2 people)
$175 Group (3-6 people)

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**Kambo Ceremonies are being facilitated also via home visits**

Kambo Compassion offers private one-on-one, small group, and larger group treatments. Also, we offer consultation to discuss any health concerns and address any inquiries leading up to your treatment.

Ceremonies include Kambo, Sananga, Hapay, and a small, healthy easy to digest meal with tea.

If you are interested in discussing Kambo or booking a ceremony then please fill out the form below and submit the application and you will be contacted shortly.

Client Form

Your Name

DOB

Phone Number

Email Address

Emergency Contact Name

Emergency Contact Phone

1. Are you currently taking any medication and what dosage? 1. Are you currently taking any medication and what dosage? Yes No

Medication

Dosage

Reason for medication

Medication

Dosage

Reason for medication

Medication

Dosage

Reason for medication

Medication

Dosage

Reason for medication

2. Are you taking any supplements? 2. Are you taking any supplements? Yes No

Supplement

Dosage

Reason

Supplement

Dosage

Reason

Supplement

Dosage

Reason

Supplement

Dosage

Reason

3. Do you have any chronic illness? 3. Do you have any chronic illness? Yes No

Condition

Duration

Please specify:

Condition

Duration

Please specify:

Condition

Duration

Please specify:

4. Do you have any current medical conditions? 4. Do you have any current medical conditions? Yes No

Condition

Duration

Please specify:

Condition

Duration

Please specify:

Condition

Duration

Please specify:

Condition

Duration

Please specify:

5. Do you have any fears or phobias? 5. Do you have any fears or phobias? Yes No

Please specify:

6. Do you or have you in the past suffered from a psychological disorder? 6. Do you or have you in the past suffered from a psychological disorder? Yes No

Please specify:

7. Are you currently taking any medication for any psychiatric disorder? 7. Are you currently taking any medication for any psychiatric disorder? Yes No

Medication

Dosage

Reason for medication

Medication

Dosage

Reason for medication

Medication

Dosage

Reason for medication

Medication

Dosage

Reason for medication

8. Have you experienced seizures or been diagnosed with epilepsy? 8. Have you experienced seizures or been diagnosed with epilepsy? Yes No

Medication

Dosage

9. Do you use stimulants and/or drugs? 9. Do you use stimulants and/or drugs? Yes No

Type

Dosage / Frequency

Reason

Type

Dosage / Frequency

Reason

Type

Dosage / Frequency

Reason

Type

Dosage / Frequency

Reason

10. Do you drink alcohol? 10. Do you drink alcohol? Yes No

If yes, how often?

11. Do you have a drug or alcohol addiction? 11. Do you have a drug or alcohol addiction? Yes No

Please specify:

12. Have you had an operation or surgery of any kind recently? 12. Have you had an operation or surgery of any kind recently? Yes No

Date

Operation / Surgery

Date

Operation / Surgery

Date

Operation / Surgery

Date

Operation / Surgery

13. Do you have a cardiovascular problem? 13. Do you have a cardiovascular problem? Yes No

Please specify:

14. Are you susceptible to fainting? 14. Are you susceptible to fainting? Yes No

Please specify:

15. Is there anything about your physical/mental state I should know about? 15. Is there anything about your physical/mental state I should know about? Yes No

Please specify:

16. Do you have previous experience working with Kambo medicine? 16. Do you have previous experience working with Kambo medicine? Yes No

Date

Points:

Date

Points:

Date

Points:

Date

Points:

9 + 9 =

Kambo cannot safely be used if you have ever had any of the following health conditions:

If you have a heart condition
If you have had a stroke
If you are on medication for low blood pressure
If you have had a brain hemorrhage
If you have had an aneurism
If you have had a blood clot
If you have a serious mental health problem
If you are currently undergoing chemotherapy or for 6 weeks afterwards
If you take immune-suppressant medication for an organ transplant
If you have had an organ transplant
If you are pregnant
If you are breastfeeding a child under 6 months of age
If you have eaten within 12 hours prior to treatment
If you have had any water based detox within 3 days prior to your Kambo treatment (for example: colonics, enemas, liver flushes)

I hereby certify that I have accurately and truthfully completed the above Client Form and read
the contraindications.

$250 Private (One-on-one)$200 Semi-Private (2 people)$175 Group (3-6 people)

Client Form

$250 Private (One-on-one)
$200 Semi-Private (2 people)
$175 Group (3-6 people)