PERSONAL INFORMATION
MENTAL & EMOTIONAL WELL-BEING
Do you have any diagnosed mental health conditions? (e.g., depression, anxiety, PTSD, bipolar disorder, etc.)
Have you ever experienced significant emotional distress or trauma?
Are you currently taking any medication for mental health? If so, please specify.
Have you ever experienced a spiritual crisis, dissociation, or psychotic episode?
How do you regulate yourself in times of disregulated states, such as anxiety, depression, or overthinking?
Do you currently have a therapist, coach, or other professional support?
Do you struggle with self-worth, self-acceptance, or feelings of inadequacy? If so, how does this manifest in your daily life?
How do you typically handle stressful situations? Do you avoid, confront, overthink, or suppress?
Do you feel emotionally resilient, or do you find yourself overwhelmed by life’s challenges?
Are you able to fully feel and process your emotions, or do you tend to suppress or avoid them?
When discomfort or fear arises, how do you normally respond? (Suppress, overanalyse, escape, fully face it, etc.)
Which emotions, if any, feel the most difficult for you to fully experience?
Do you feel safe in your own body? If not, what prevents that sense of safety?
Have you ever had long periods of emotional numbness or disconnection from yourself? If so, how do you experience it?
PYHSICAL HEALTH
Do you have any chronic illnesses or medical conditions?
Are you currently taking any medications (excluding mental health medication)?
Do you have any history of seizures, heart conditions, or other physical conditions that may impact your participation?
Do you have any physical limitations that may affect your ability to engage in movement practices, breathwork, or meditation?
Do you regularly exercise, and if so, what type?
Do you have a healthy relationship with food, or do you experience emotional eating patterns?
How many units of alcohol do you typically consume per week?
Do you use any other substances (cannabis, stimulants, etc.)? If so, how frequently?
PERSONAL & SPIRITUAL PRACTICES
Who are you? (Describe how you see yourself)
What practices do you adopt, if any, in your life to support yourself? (e.g., somatic movements, meditation, breathwork, journaling, exercise, etc.)
Do you have a regular meditation or mindfulness practice? If so, how often do you practice?
Have you explored non-duality teachings before? If so, what has been your experience?
Do you struggle to sit with stillness, or do you find comfort in silence and presence?
How do you navigate uncertainty and surrender?
Do you have a daily routine that supports inner awareness, and if not, what stops you from implementing one?
How do you reconnect with yourself when feeling disconnected?
Do you tend to intellectualise spirituality, trying to "figure it out," or are you open to experiencing it directly?
ENTHEOGEN & PSYCHEDELIC EXPERIENCE
Have you worked with entheogens such as psilocybin, ayahuasca, LSD, or 5-MeO-DMT?
Have you ever had a challenging or traumatic psychedelic experience? If so, how did you integrate it?
Are you currently microdosing? If so, what are you using and how often?
What have been the most profound insights or challenges you’ve faced in psychedelic experiences?
Have you ever relied on psychedelics for insight rather than developing your inner awareness without substances?
What role do you believe psychedelics should play in personal transformation?
Do you feel that past psychedelic experiences have helped or hindered your journey towards presence?
What is your biggest concern or hesitation about working with Ayahuasca?"
LOCUS OF CONTROL & SELF-PERCEPTION
Please rate each statement on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree).
Assessment Questions:
I believe that my thoughts, actions, and awareness primarily shape my life rather than external circumstances.
My emotional state is mostly within my control, regardless of what happens around me.
When things go wrong, I take full ownership of my response rather than blaming external factors.
I see challenges as opportunities for growth rather than obstacles beyond my control.
I take responsibility for my healing and do not expect others to “fix” me.
I actively work to shift unhelpful patterns in my life rather than blaming them on my past.
I do not depend on external validation to feel at peace within myself.
I trust that clarity arises from within rather than needing constant external guidance.
I take ownership of my reactions rather than attributing them to external triggers.
I believe lasting peace is found through direct experience rather than intellectual understanding.
I am willing to challenge deeply held beliefs that may be limiting me.
I recognise that suffering is often created by resistance to what is.
I acknowledge that my past does not define my present or my future.
I am willing to sit with discomfort rather than seek distractions.
I trust that the deeper truth is already here, beyond my thoughts and beliefs.
COMMITMENT & INTEGRATION
Are you prepared to commit to weekly lessons, practices, and group calls for the full 8 weeks?
What does true commitment to self-growth look like to you?
How do you integrate insights from self-exploration into your daily life?
Do you have a practice of self-reflection or journaling? If not, would you be open to developing one?
What challenges do you foresee in committing fully to this process?
Are you willing to be open, honest, and fully show up for yourself in this work?
What does freedom mean to you, in your own words?
How do you usually respond to resistance or discomfort when engaging in inner work?
Is there anything else you feel we should know about you to support you fully in this journey?
FINAL ACKNOWLEDGMENT
Name
Name
Date
Date
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