M Group Ceremony Questionnaire

Contact Information

Name *

Phone *

Email (Use the same as Soultech Sanctum membership) *

Birthdate *

Emergency Contact Info

In the rare event of an emergency, we will call 911 and contact emergency personnel to support your highest needs. In addition, we want to know who you'd like us to contact.

Emergency Contact Name *

Emergency Contact (Relationship) *

Phone

Intention & Emotional State of Being

What is your main intention? Tell us why you're interested in participating in a MDMA Group Ceremony? *

Is this your first time experiencing MDMA?

Yes
No

Do you have any experience with other psychedelics and/or Sacred Medicines?

Yes
No

How many times in the past 6-months have you used recreational and/or hallucinogenic drugs (outside a healing/sacred context)?

Do you believe in the inner healing intelligence of your body?

Yes
No

What are your concerns or fears for the upcoming group ceremony? (If any) *

Are there any previous trauma’s that are currently impacting your life? (Or anything you feel that is blocking you from embracing more light and love into your life? *

What, if any, are the major sources of stress in your life currently, or events that have occurred recently that have impacted your emotional, physical and/or mental wellbeing? *

Current Home & Community Environment

Are there key people in your support network that are aware of your interest in a Sacred Molecule group ceremony and are supportive with this type of medicine? Please explain: *

Who in your life might be most impacted if your experience leads to new insights, breakthroughs, or changes?

Do you feel safe at home? (If no, please explain)

Yes
No

How open are you to surrendering to new experiences in life? *

Not very
Somewhat
Very open

How often do you feel the need to control things in your life? *

All the time
Frequently
Rarely
Never

Western Medical Healthcare Systems

Have you ever been hospitalized for a psychiatric reason?

Yes
No

Do you currently have any suicidal thoughts or past suicide attempts?

Yes
No

List your prescription medications. *

What over the counter supplements and/or herbs have you taken in the past 6-months?

Please note this is not meant to be a complete resoure list of medications. These medications have potential dangerous interactions and are contraindications. If you are on any of these medications please discuss with your healthcare professional and discuss with Soultech ahead of your ceremony to ensure for a safe and optimal ceremony.

Serious Contraindications:
- MAOIs (e.g Harmala alkaloids, Syrian rue, Ayahuasca, Moclobemide, Phenelzine (Nardil), Tranylcypromine (Parnate), Selegiline (Emsam), Isocarboxazid (Marplan), Methylene blue, and Linezolid
- Lithium - Increased risk of seizures or serotonin toxicity
These medications below have a risk of increased serotonin levels and Serotonin Syndrome.
- SSRIs (e.g., fluoxetine, paroxetine, escitalopram, fluvoxamine, citalopram, sertraline)
- SNRIs (e.g., duloxetine, venlafaxine, desvenlafaxine)
- SPARIs (e.g., vortioxetine, vilazodone)
- Buspirone
- Mirtazapine
- Trazodone, Nefazodone
- Atypical antipsychotics
- TCAs with potent SRI properties (e.g., Chlorpheniramine, clomipriamine, imipramine)
- St. John’s Wort
- Other stimulants (e.g., Adderall, Vivance, Nicotine in high doses, cocaine, ephedra, weight loss agents, pseudoephedrine)
- Opioids & Pain Medications, Increased Risk of Respiratory Depression & Overdose (Oxycodone, OxyContin, Percocet, Hydrocodone, Vicodin, Norco, Morphine, Fentanyl, Codeine, etc.)
-Medications That Affect the Liver, Slowed MDMA Metabolism, Increased Toxicity - (Cimetidine (Tagamet), Ritonavir (HIV medication), Fluoxetine (Prozac), Quinidine (Anti-arrhythmic medication))

Do you have any known allergies that you know cause you adverse reactions?

Yes
No

Please list the severity and type (food, nuts, gluten intolerance, pets, etc.)

Do you have any other medical conditions or concerns that you want to share with us ahead of time?

Yes
No

Ceremony Optimization

How comfortable are you with supportive touch from facilitators or other group participants to support your experience?

	Don't want to be touched	Don't like supportive touch	Neutral	Like supportive touch	Love supportive touch!
Supportive Touch	Don't want to be touchedSupportive Touch Don't want to be touched	Don't like supportive touchSupportive Touch Don't like supportive touch	NeutralSupportive Touch Neutral	Like supportive touchSupportive Touch Like supportive touch	Love supportive touch!Supportive Touch Love supportive touch!

Would you be interested in learning more about Psycho-Spiritual and/or Psychedelic Integration Coaching to support your personal integration journey after the group ceremony?? *

Yes
No

Is there anything else you’d like to share that wasn't included above or you'd like to emphasize?

MDMA is a powerful tool. Working with this sacred molecule, and participating in Soultech Group Ceremonies, requires active engagement and participation in your own healing and empowerment journey. Soultech will provide prep guide, education, facilitation, and post-integration support, a safe community and more, however it is crucial to take ownership for your own actions and healing journey. The following agreements demonstrate that you are ready to actively engage in your life optimization and personal empowerment practice, and thus participate in a Group Ceremony.

Personal Liability and Indemnity Waiver

I agree to indemnify and hold harmless Soultech Sanctum against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me, or anyone on my behalf, including attorney's fees and any related costs.

Non-Sexual Environment

I acknowledge that this experience may enhance feelings of love, connection, and openness, which can create deep emotional and energetic bonds. I understand that while these feelings are natural, this ceremony is a sacred, non-sexual space designed for heart-centered healing, self-discovery, and community connection. I agree to honor and uphold clear boundaries by refraining from any sexual touch, advances, or activity during or immediately after the ceremony with anyone I am not already in a committed and intimate relationship with. I understand that consent and energetic integrity are fundamental to maintaining the safety and sacredness of this experience.

Emergency Procedures Waiver

In the very unlikely event of an emergency, you give Soultech Sanctum representatives permission to call emergency personnel (ambulence, etc.) in accordance with Soultech Sanctum standard emergency procedures to support your highest safety and wellbeing.

Mental and Emotional Awareness Consent

I understand that in working with sacred medicine some buried memories & experiences may resurface so that I have the opportunity to neutralize & transform them. I am open to deep healing. If I have experienced deep trauma in my life and haven't made time to process it, I will seek professional help so that I am fully supported.

Medical Disclaimer

I understand that Soultech Sanctum spiritual ceremonies are for informational, transformational purposes only and are not intended to be a substitute for professional medical advice, care, diagnosis, or treatment. Always seek the advice of your physician or other qualified health providers with any questions you may have regarding a medical or mental condition.

Soultech Sanctum Group Ceremony Questionnaire