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Les Niñes Sagrades Assessment

Thank you for your interest in Les Niñes Sagrades Ritual! 

Please complete this assessment asap to prepare.

This will take 10 - 15 min to complete.

After your assessment has been reviewed and approved, you will receive more information on joining the sacred ritual.

For any questions, please email madaly@madaly.love.

Tlazocamati / Thank you!

Click the button below to start.

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Question 1 of 26

Full Name:

Question 2 of 26

Age:

Question 3 of 26

Pronouns:

Question 4 of 26

Address: (to send medicine, it is safe through USPS)

Question 5 of 26

Contact Information (Phone Number/Email):

Question 6 of 26

Emergency Contact Information (Name/Phone Number/Relationship):

Question 7 of 26

How did you find Madaly? Did someone refer you? If so, who?

Medical History

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Question 9 of 26

Do you have any existing medical conditions? If yes, please specify.

Question 10 of 26

Are you currently taking any prescription medications? If yes, please specify.

Question 11 of 26

Have you ever been diagnosed with any mental health disorders (e.g., depression, anxiety, PTSD, schizophrenia, bipolar disorder)? If yes, please specify.

Question 12 of 26

Are you currently receiving treatment or therapy for any mental health concerns? If so, do you feel supported in your mental health resources if anything were to come up during the ritual?

Psychedelic Experience

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Question 14 of 26

Have you ever participated in a plant medicine/psychedelic ceremony or used plant medicine/psychedelic substances (such as psilocybin, LSD, ayahuasca, etc.) before?

If so, which medicines and please describe your experiences and any insights gained.

Question 15 of 26

Have you ever experienced any adverse reactions or allergies to plant medicine or psychedelic substances?

Expectations and Intentions

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Question 17 of 26

What are your intentions for participating in this microdosing ritual?

Question 18 of 26

What do you hope to gain or learn from this experience?

Support System

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Question 20 of 26

Do you have a support system in place for before, during, and after the ritual?

A

Yes

B

No

Question 21 of 26

Are you comfortable discussing your participation in the ritual with friends, family, or a therapist if needed?

A

Yes

B

No

Logistics

Thank you for completing this section

Question 23 of 26

Are you able to commit to the full duration of the ritual (March 4 - April 29), which includes preparation and integration?

Question 24 of 26

    1. Do you have any concerns about the ritual (zoom calls, receiving the medicine, the microdose protocol. group chat, the facilitator, etc)?

 

Question 25 of 26

Is there any additional information you would like to share about yourself or your expectations for Les Niñes Sagrades Ritual?

Question 26 of 26

Les Niñes Sagrades Ritual Agreement

By embarking on a Les Niñes Sagrades Ritual, the client agrees to the following terms and conditions:

  • Voluntary Participation: The client acknowledges that participation in the Les Niñes Sagrades Ritual is entirely voluntary and that they have chosen to engage in this protocol of their own free will.

  • Informed Consent: The client understands that Les Niñes Sagrades is a controlled substance and that the microdosing protocol involves the regular consumption of small doses of Les Niñes Sagrades. The client acknowledges that they will be provided with information regarding the potential risks, benefits, and effects of Les Niñes Sagrades microdosing and have had the opportunity to ask questions and seek clarification if needed.

  • Medical Consultation: If needed, the client agrees to consult with a qualified healthcare professional prior to starting the microdosing protocol to ensure that they do not have any underlying medical conditions or contraindications that could be exacerbated by the use of Les Niñes Sagrades.

  • Responsibility for Dosage: The client understands that they are solely responsible for obtaining and measuring their doses of Les Niñes Sagrades accurately and safely. The client agrees to follow the recommended dosage guidelines provided by their healthcare professional or the protocol facilitator.

  • Safety Precautions: The client agrees to consume Les Niñes Sagrades only in a safe and controlled environment and to refrain from operating heavy machinery or engaging in activities that require full cognitive function while under the influence of Les Niñes Sagrades.

  • Monitoring and Reporting: The client agrees to monitor their physical, emotional, and mental well-being throughout the duration of the microdosing protocol and to promptly report any adverse reactions, side effects, or concerns to their healthcare professional or protocol facilitator.

  • Confidentiality: The client understands that information shared during the microdosing protocol, including personal experiences and insights, will be kept confidential by the facilitator and/or healthcare professional, unless required by law.

  • Termination of Protocol: The client acknowledges that the microdosing protocol may be terminated or modified at any time by their healthcare professional or protocol facilitator if it is deemed necessary for their safety or well-being.

  • Acknowledgment of Limitations: The client understands that while Les Niñes Sagrades microdosing may have therapeutic potential, it is not a substitute for professional medical or psychological treatment. The client agrees to continue any existing treatment plans as recommended by their healthcare professional.

  • Assumption of Risk: The client acknowledges that there are inherent risks associated with the use of Les Niñes Sagrades, including but not limited to psychological distress, adverse reactions, and legal consequences. The client agrees to assume all risks associated with participation in the microdosing protocol.

 

By checking the box below, the client acknowledges that they have read and understood the terms of this agreement and agree to abide by them throughout the duration of the Les Niñes Sagrades Ritual.

(Select all that apply)
A

Yes I acknowledge that I have read and understand the terms of this agreement and agree to abide by them throughout the duration of the Les Niñes Sagrades Ritual.

Confirm and Submit