Health Form -

PLEASE READ

Agree

This form is confidential and forms part of your preparation for participation in a traditional healing and ceremonial practice facilitated by a registered Traditional Health Practitioner in accordance with the Traditional Health Practitioners Act, 22 of 2007 (South Africa). The purpose of this form is to: support participant safety, assess suitability for ceremonial participation, and ensure informed, voluntary consent. Participation is entirely optional, and completion of this form does not guarantee acceptance into any ceremony. All information provided will be handled in accordance with the Protection of Personal Information Act (POPIA). PRACTITIONER DISCLOSURE: The facilitator of this ceremony is a registered Traditional Healing Practitioner, practising within the scope of traditional and ancestral healing. This service is not medical, psychological, or psychiatric treatment, and is not a substitute for professional healthcare. Participants are encouraged to consult a medical doctor, psychologist, or psychiatrist before participation if they have any health concerns.

Name

Surname

Phone Number

Age

Current City

Gender

Nationality:

Emergency Contact Name

Emergency Contact Number

MEDICAL & PHYSICAL HEALTH INFORMATION

I understand

Please answer honestly. Providing inaccurate or incomplete information may increase personal risk and may result in exclusion from participation.

Are you pregnant

Are you breastfeeding

Do you have any current or past injuries or physical conditions that may affect your participation in a ceremony ?

(e.g. fainting, balance issues, heart conditions)

If yes, please describe:

Do you or have you had a history of high/low blood pressure or hypertension:

Have you fainted in the last 12 months?

Do you have diabetes, asthma, epilepsy, seizures, Crohn’s disease, ulcers, or other chronic conditions?

If yes, please describe:

Do you have any known allergies (including plant, food, or environmental allergies)?

If yes, please describe:

Have you had any surgery or medical procedures in the last 6 months?

If yes, please describe:

Have you ever been diagnosed with or experienced serious mental or psychological conditions, including but not limited to: Psychosis Schizophrenia Bipolar Disorder Severe dissociation Manic episodes

the or

If yes, please describe (dates, current status):

Are you currently taking medication for mental health or neurological conditions?

If yes, please list medications and dosages:

Have you experienced suicidal thoughts or impulses in the past?

Are you currently in therapy or part of a support group?

Are you currently taking any prescription medication, supplements, or herbal remedies?

Supplements such as Ginseng, St John’s Wort, Sceletium (Kanna), or any other supplement containing 5HTP (please check your supplement bottle carefully)? These supplements are contra-indicated and should be stopped at least a month before participation in the ceremony.

If yes, please list:

Have you used recreational drugs or stimulants in the last 6 months?

Do you or have you in the last 3 months used Crystal Meth / Cocaine/ Khat?

Do you have previous experience with traditional plant or ceremonial practices?

If yes, please describe briefly:

Are there any physical, emotional, or mental factors you believe the facilitator should be aware of for safety reasons?

If yes, please elaborate:

INFORMED CONSENT, ASSUMPTION OF RISK & LIMITATION OF LIABILITY

By signing below, I confirm that: I have read and understood this form in full. I have had the opportunity to ask questions. I consent freely and without pressure.
I do not consent

I acknowledge and agree that:

Nature of the Practice
I understand that I am participating in a traditional healing ceremony rooted in spiritual, cultural, and ancestral practices. This is not medical treatment, psychotherapy, or clinical intervention.

Voluntary Participation
My participation is entirely voluntary. I may withdraw my consent and participation at any time before or during the ceremony.

Personal Responsibility
I accept full responsibility for my decision to participate and for my physical, emotional, mental, and spiritual well-being during and after the ceremony.

Potential Risks
I understand that ceremonial participation may involve physical, emotional, psychological, or spiritual discomfort, including but not limited to:

nausea or vomiting

dizziness or fatigue

emotional release or distress

temporary confusion or disorientation

No Guarantees
I understand that no guarantees or promises are made regarding outcomes, healing, insight, or benefit of any kind.

Self-Administration & Autonomy
I acknowledge that participation involves my own personal choice and agency. I am responsible for listening to my body and communicating my needs.

Limitation of Liability
To the fullest extent permitted by South African law, I agree that the facilitator and Health by Soul shall not be held liable for adverse effects, injuries, emotional distress, or losses arising from my voluntary participation, except in cases of gross negligence or intentional misconduct.

Truthfulness
I confirm that all information provided in this form is accurate and complete to the best of my knowledge.

Privacy & Data Protection
I consent to the collection and secure storage of my personal and health information for the sole purpose of participant safety and preparation, in accordance with POPIA. I understand I may request access to or deletion of my data.

Health Form

healthbysoul_1

Follow Us