Jenny Schiltz - Visionary healing Retreats 2

Are you ready to take the leap?

Fill out the intake form

Once that is reviewed and all your questions are answered, you will be sent an invoice so that you can pay your deposit.

Retreat Intake form (#53)

First Name

Last Name

This intake form is for:

Are you interested in a Kambo healing ceremony if available?

Yes

No

Email

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth

Emergency Contact Name and Phone number

How did you hear about doing Plant & Jungle medicines with Jenny & Danny Schiltz?

What made you want to work with these medicines? What are you wanting help with?

What is your Personal experience working with conscious altering/psychedelic medicines?

Do you have personal experience with other plant/animal based medicine?

Are you pregnant or think that you might be pregnant?

Yes

No

Do you have any serious heart conditions including pace maker, valve disease, bypass surgery or enlarged heart

Yes

No

If the answer is yes, please provide detail

Do you suffer from high or low blood pressure?

Yes

No

Do you have any cardiovascular conditions? If yes, please detail

Have you ever had a stroke, aneurysm or bleeding on the brain?

Yes

No

Are you currently or have you ever received Therapy, attended a support Group and/or worked with a counselor, psychiatrist, psychologist or psychotherapist? If yes, please elaborate.

Is there anyone in your family with a history of psychiatric disorders?

Yes

No

If yes, please explain the relation and the diagnosis

Have you experienced traumas in your life? This includes traumatic events as well as ongoing traumatic experiences. If yes, please explain.

If YES, has this influenced your desire to work with plant & jungle medicines?

Yes

No

Do you drink alcohol?

Yes

No

If YES, are you willing to fully detox off of any alcoholic substances a minimum of 7 days prior to Your Ceremony?

Yes

No

Are you taking ANY western medical prescriptions, over-the-counter, or alternative, homeopathic medications or taking herbal supplements ? If so, please list below and explain.....

Are you taking a SSRI, SNRI, or MAIO inhibitors?

Yes

No

If YES, are you willing to stop taking your medicine up to 2 weeks prior to Your Ceremony? *Please check with your doctor before stopping any medication*

Yes

No

Which SSRI, SNRI, or MAIO inhibitor are you taking? Each one has a different amount of time needed detox prior to the retreat.

Is there anything else we should know about your physical or mental state?

Do you have any allergies?

Do you have any food allergies or diet restrictions?

Do you have any questions for us?

Jenny is a badass mother, grandma, and businesswoman who blazes down the medicine path, diving into consciousness with psychedelics to expand & heal herself into the biggest version of herself. She then brings this work to her clients, helping them to heal and be their most authentic version of themselves.

Annell

Meet your hosts – Jenny & Dan Schiltz:

We have been Divine Partners for more than 30 years, raising 4 children and we are now blessed with 4 grandchildren. As a couple, our healing journey began the moment we met.

Now we have joined as Divine Healing Partners, training together on various plant and jungle medicines that have shifted and awakened us to even deeper levels within ourselves and within our relationship.

“My experience with Jenny and Danny was profound on an emotional, spiritual, and molecular level. The ceremony and medicine are a little like a cheat sheet, it gives you permission to bypass years of meditation and introspect to break through your barriers in an unexplainable experience. Thank you, Jenny and Danny, for taking on the path of being tools of the Almighty.”

Johanna