{"id":873,"date":"2020-08-22T20:40:43","date_gmt":"2020-08-22T20:40:43","guid":{"rendered":"https:\/\/kambodawn.com\/?page_id=873"},"modified":"2021-03-10T15:32:56","modified_gmt":"2021-03-10T15:32:56","slug":"forms","status":"publish","type":"page","link":"https:\/\/kambodawn.com\/?page_id=873","title":{"rendered":"Session Forms"},"content":{"rendered":"\n<p style=\"font-size:25px\"><strong>NOTE:<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>If you have a previously scheduled a session please complete the following forms.<\/li><li>If you need to schedule a session please follow the &#8220;Book a Session&#8221; link from the menu above.<\/li><\/ol>\n\n\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><style>#gform_wrapper_5[data-form-index=\"0\"].gform-theme,[data-parent-form=\"5_0\"]{--gform-theme-color-primary: #204ce5;--gform-theme-color-primary-rgb: 32, 76, 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height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gform-theme-control-border-color: #686e77;--gform-theme-control-size: var(--gform-theme-control-size-md);--gform-theme-control-label-color-primary: #112337;--gform-theme-control-label-color-secondary: #112337;--gform-theme-control-choice-size: var(--gform-theme-control-choice-size-md);--gform-theme-control-checkbox-check-size: var(--gform-theme-control-checkbox-check-size-md);--gform-theme-control-radio-check-size: var(--gform-theme-control-radio-check-size-md);--gform-theme-control-button-font-size: var(--gform-theme-control-button-font-size-md);--gform-theme-control-button-padding-inline: var(--gform-theme-control-button-padding-inline-md);--gform-theme-control-button-size: var(--gform-theme-control-button-size-md);--gform-theme-control-button-border-color-secondary: #686e77;--gform-theme-control-file-button-background-color-hover: #EBEBEB;--gform-theme-field-page-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F873#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_below'><li id=\"field_5_1\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\"><Strong><P>Welcome!<\/P>\n<P>Thank you for your interest in a Kambo Treatment. I am a certified Kambo Practitioner and full member of the International Association of Kambo Practitioners (I.A.K.P.).<\/P>\n<P>I work according to the IAKP\u2019s Codes of Practice. Before the treatment, I provide you with a personal consultation. During your Kambo Journey I will hold space for you to be in your process.<\/P>\n<P>Please conduct your own research to ensure you feel comfortable with being treated with Kambo. Our Website is a great resource: www.KamboDawn.com<\/P>\n<P>The popularity and use of Kambo as a natural treatment is spreading worldwide. As the research into the secretion of the Phyllomedusa bicolor grows, skilled practitioners are also developing new ways to work with this powerful substance from the Amazonian Forest that allows it to be accessible to almost everyone in a safe and manageable way.<\/P>\n<P>Not only do we now have several different traditional ways to work with Kambo but we can also work with the Meridians, the Chakras and the ears \u2013 Auricular Kambo.  Added to this, there are also new techniques to allow people to take Kambo in a way that is gentler on their system but still allows them to enjoy the maximum benefits. We will discuss your intentions for participating in the Kambo sitting with you prior to the beginning of the session to determine the treatment that would serve you best. Our mission is to ultimately serve you, so please understand that you have the  final say in any treatment you receive.<\/P>\n<P><B>Recommendations for your session:<\/B><\/P>\n<P><UL><LI>Wear loose, comfortable clothing. For traditional Kambo application (Kambo is placed on the upper arm or lower leg) please wear a t-shirt or tank top and comfortable pants that can easily be rolled up at the ankle.<\/LI>\n<LI>If you are receiving a chakra treatment (Kambo is placed along the spine) we recommend clothing that allows access to the back. Men traditionally remove their shirts if this is uncomfortable a loose tank top that can be tied in the back is recommended. For women a backless tank top or sports bra. We honor and respect the need for women and men to feel safe during their treatment. My wife and I work together to ensure that everyone feels safe during the ceremonial process. If you have any questions regarding proper attire please contact us.<\/LI>\n<LI>A change of clothes;<\/LI>\n<LI>Do not eat food for 12 hours beforehand. We recommend not consuming water for 12 hours prior, however you may sip water (12 ounces or less) and have an herbal tea with a teaspoon of honey 2 hours before your treatment. We have found that scheduling a morning session can make it easier to follow the food and water restriction guidelines. The general rule is to stop consuming food and water around midnight the night before your treatment and refrain from consuming food or water prior to your arrival in the morning, if possible.<\/LI>\n<LI>When you arrive for your appointment you will drink to 2 liters of water 10-15 minutes before the Kambo is applied. We will provide the water. All water consumed has been charged with healing prayers specific to the individual. Please wait until we tell you before you begin drinking.<\/LI>\n<LI>Do not consume alcohol, drugs or other substances for 24-48 hours before or after the Kambo treatment;<\/LI>\n<LI>Avoid food that is strong on the liver for 24-48 hours prior to and after Kambo, e.g. saturated fats found in butter, sour cream, and other high-fat dairy foods, fatty cuts of meat, fried foods, sugary treats like cookies, cake, soft drink, and packaged baked goods.<\/LI><\/UL><\/P>\n \n<P><B>Application &#038; What to Expect:<\/B><\/P>\n\n<P>Kambo is applied through \u201cgates\u201d; meaning that the top layer of the skin or epidermis will be burned first with a natural incense stick so that a blister will form. I will then pop the small blister to open a pathway or \u201cgate\u201d for the Kambo to enter the body. Once the Kambo has been applied, it is distributed throughout the body via the lymphatic system. For a short while you will experience an elevated body temperature  along with increased heart rate, fast dilation of the blood vessels causing a pounding or rushing sensation, slight swelling of the lips, face and tightness in the throat, skin tingling, some dizziness. You will then begin the purge which removes toxins that have been store in the body; Kambo also works on a physical and emotional level, so during this process, you may receive insights and messages that are energetic or spiritual in nature.<\/P>\n<P>Please know that this work can be exhausting; a rest is needed after your process. We will be offering herbal teas and light refreshments that typically consist of fruits, vegetables, hummus and crackers to energize your body after your treatment. Some feel the Kambo\u2019s benefits immediately and others within 24-48hrs. Most importantly, always trust your process!<\/P>\n<P>Sananga (eye tincture) and Rap\u00e9 (sacred snuff) will be offered prior to and\/or after the Ceremony. <\/P>\n<P>We look forward to assisting you along your path.<\/P>\n<P>If you have any further questions please don\u2019t hesitate to contact us.<\/P>\n<P><B>Other considerations:<\/B><\/P>\n<P><UL><LI>People with asthma need to bring their inhaler with them;<\/LI>\n<LI>Diabetics need to bring insulin, testing strips and extra food;<\/LI>\n<LI>Menstruation flow may increase for 24 \u2013 36 hours following a Kambo treatment <\/LI><\/UL><\/P>\n\n<P>Aloha &#038; Blessings,<\/P>\n<P>Your Kambo Dawn Family.<\/P><\/Strong><\/li><li id=\"field_5_10\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_5_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_2'>\n                            \n                            <span id='input_5_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_2.3' id='input_5_2_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_5_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_2.6' id='input_5_2_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_3\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\"><label class='gfield_label gform-field-label' for='input_5_3' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_5_3' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_4\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\"><label class='gfield_label gform-field-label' for='input_5_4' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_5_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_5\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\"><label class='gfield_label gform-field-label' for='input_5_5' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_6\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_6_1_container' >\n                                        <label for='input_5_6_1' id='input_5_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_6.1' id='input_5_6_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_6_2_container' >\n                                        <label for='input_5_6_2' id='input_5_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_6.2' id='input_5_6_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_6_3_container' >\n                                    <label for='input_5_6_3' id='input_5_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_6.3' id='input_5_6_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_6_4_container' >\n                                        <label for='input_5_6_4' id='input_5_6_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_6.4' id='input_5_6_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_6_5_container' >\n                                    <label for='input_5_6_5' id='input_5_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_6.5' id='input_5_6_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_6_6_container' >\n                                        <label for='input_5_6_6' id='input_5_6_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_6.6' id='input_5_6_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_7\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\"><label class='gfield_label gform-field-label' for='input_5_7' >Emergency Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_8\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\"><label class='gfield_label gform-field-label' for='input_5_8' >Emergency Contact Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_11\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_11\"><h2 class=\"gsection_title\"><\/h2><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_9' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_2' class='gform_fields top_label form_sublabel_above description_below'><li id=\"field_5_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\"><label class='gfield_label gform-field-label'  >What type of session are you interested in?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_44'>\n\t\t\t<li class='gchoice gchoice_5_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Series of 3 sessions, private (3 or fewer people)'  id='choice_5_44_0'    \/>\n\t\t\t\t<label for='choice_5_44_0' id='label_5_44_0' class='gform-field-label gform-field-label--type-inline'>Series of 3 sessions, private (3 or fewer people)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Single session, private (3 or fewer people)'  id='choice_5_44_1'    \/>\n\t\t\t\t<label for='choice_5_44_1' id='label_5_44_1' class='gform-field-label gform-field-label--type-inline'>Single session, private (3 or fewer people)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_44_2'>\n\t\t\t\t<input name='input_44' type='radio' value='Group session (4 or more people)'  id='choice_5_44_2'    \/>\n\t\t\t\t<label for='choice_5_44_2' id='label_5_44_2' class='gform-field-label gform-field-label--type-inline'>Group session (4 or more people)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_44_3'>\n\t\t\t\t<input name='input_44' type='radio' value='Unsure'  id='choice_5_44_3'    \/>\n\t\t\t\t<label for='choice_5_44_3' id='label_5_44_3' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_13\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\"><label class='gfield_label gform-field-label' for='input_5_13' >How did you hear about Kambo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\"><label class='gfield_label gform-field-label'  >Have you ever experienced Kambo before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_45'>\n\t\t\t<li class='gchoice gchoice_5_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Yes'  id='choice_5_45_0'    \/>\n\t\t\t\t<label for='choice_5_45_0' id='label_5_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_5_45_1'    \/>\n\t\t\t\t<label for='choice_5_45_1' id='label_5_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_46\"><label class='gfield_label gform-field-label'  >Kambo is a sacred and benevolent tool. Are you able to treat the experience with respect and responsibility?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_46'>\n\t\t\t<li class='gchoice gchoice_5_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_5_46_0'    \/>\n\t\t\t\t<label for='choice_5_46_0' id='label_5_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_5_46_1'    \/>\n\t\t\t\t<label for='choice_5_46_1' id='label_5_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_46_2'>\n\t\t\t\t<input name='input_46' type='radio' value='Unsure'  id='choice_5_46_2'    \/>\n\t\t\t\t<label for='choice_5_46_2' id='label_5_46_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_18\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\"><label class='gfield_label gform-field-label' for='input_5_18' >What is your interest in working with Kambo (what is your intention)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_5_18' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\"><label class='gfield_label gform-field-label'  >Have you ever worked with &quot;Plant Medicines&quot; such as Ayahuasca, San Pedro (Huachuma), Iboga, Mushrooms, or Rap\u00e9 (Hapay)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_47'>\n\t\t\t<li class='gchoice gchoice_5_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Yes'  id='choice_5_47_0'    \/>\n\t\t\t\t<label for='choice_5_47_0' id='label_5_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='No'  id='choice_5_47_1'    \/>\n\t\t\t\t<label for='choice_5_47_1' id='label_5_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_20\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\"><label class='gfield_label gform-field-label' for='input_5_20' >If you have worked with &quot;Plant Medicines&quot;, which ones, how often and when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_5_20' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_21\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\"><label class='gfield_label gform-field-label' for='input_5_21' >What are some areas of your life where you feel blocked or would like improvement? For example, career, wellness, motivation, clarity, etc. Please explain:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_5_21' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_42' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_42' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-42' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_3' class='gform_fields top_label form_sublabel_above description_below'><li id=\"field_5_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\"><label class='gfield_label gform-field-label'  >Do you currently have any health problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_48'>\n\t\t\t<li class='gchoice gchoice_5_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_5_48_0'    \/>\n\t\t\t\t<label for='choice_5_48_0' id='label_5_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_5_48_1'    \/>\n\t\t\t\t<label for='choice_5_48_1' id='label_5_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_22\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\"><label class='gfield_label gform-field-label' for='input_5_22' >If you answered yes above, please be 100% transparent, clear and precise with your information:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_5_22' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_49\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\"><label class='gfield_label gform-field-label'  >Have you suffered any health problems in the past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_49'>\n\t\t\t<li class='gchoice gchoice_5_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_5_49_0'    \/>\n\t\t\t\t<label for='choice_5_49_0' id='label_5_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_5_49_1'    \/>\n\t\t\t\t<label for='choice_5_49_1' id='label_5_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_23\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\"><label class='gfield_label gform-field-label' for='input_5_23' >If you answered &quot;YES&quot; above, please be 100% transparent, clear and precise with your information:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_5_23' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_50\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\"><label class='gfield_label gform-field-label'  >Have you or anyone in your family ever experienced depression or anxiety?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_50'>\n\t\t\t<li class='gchoice gchoice_5_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_5_50_0'    \/>\n\t\t\t\t<label for='choice_5_50_0' id='label_5_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_5_50_1'    \/>\n\t\t\t\t<label for='choice_5_50_1' id='label_5_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_24\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\"><label class='gfield_label gform-field-label' for='input_5_24' >If you answered &quot;YES&quot; above, please be 100% transparent, clear and precise with your information:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_5_24' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_51\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\"><label class='gfield_label gform-field-label'  >On average, how many glasses of water do you drink per day?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_51'>\n\t\t\t<li class='gchoice gchoice_5_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='None'  id='choice_5_51_0'    \/>\n\t\t\t\t<label for='choice_5_51_0' id='label_5_51_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='1 -- 2'  id='choice_5_51_1'    \/>\n\t\t\t\t<label for='choice_5_51_1' id='label_5_51_1' class='gform-field-label gform-field-label--type-inline'>1 &#8212; 2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_51_2'>\n\t\t\t\t<input name='input_51' type='radio' value='3 -- 5'  id='choice_5_51_2'    \/>\n\t\t\t\t<label for='choice_5_51_2' id='label_5_51_2' class='gform-field-label gform-field-label--type-inline'>3 &#8212; 5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_51_3'>\n\t\t\t\t<input name='input_51' type='radio' value='6 - 8'  id='choice_5_51_3'    \/>\n\t\t\t\t<label for='choice_5_51_3' id='label_5_51_3' class='gform-field-label gform-field-label--type-inline'>6 &#8211; 8<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_51_4'>\n\t\t\t\t<input name='input_51' type='radio' value='9 -- 11'  id='choice_5_51_4'    \/>\n\t\t\t\t<label for='choice_5_51_4' id='label_5_51_4' class='gform-field-label gform-field-label--type-inline'>9 &#8212; 11<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_51_5'>\n\t\t\t\t<input name='input_51' type='radio' value='12 or more'  id='choice_5_51_5'    \/>\n\t\t\t\t<label for='choice_5_51_5' id='label_5_51_5' class='gform-field-label gform-field-label--type-inline'>12 or more<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_52\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\"><label class='gfield_label gform-field-label'  >Are you currently taking any herbs, prescribed or over-the-counter medications or supplements?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_52'>\n\t\t\t<li class='gchoice gchoice_5_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_5_52_0'    \/>\n\t\t\t\t<label for='choice_5_52_0' id='label_5_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_5_52_1'    \/>\n\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_26\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\"><label class='gfield_label gform-field-label' for='input_5_26' >If you answered &quot;YES&quot; above, please list ALL supplements, herbs, and medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_5_26' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_43' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_43' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-43' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_4' class='gform_fields top_label form_sublabel_above description_below'><li id=\"field_5_28\"  class=\"gfield gfield--type-multiselect gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\"><label class='gfield_label gform-field-label' for='input_5_28' >Certain medications and situations are not compatible with Kambo. Stopping certain substances and medications can be very dangerous and is not recommended without seeking professional medical assistance. These medications and substances can include (please select all that are applicable):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple' data-placeholder='Click to select...' size='7' name='input_28[]' id='input_5_28' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='Alcohol dependency' >Alcohol dependency<\/option><option value='Alcohol -- High doses' >Alcohol &#8212; High doses<\/option><option value='Alcohol -- Medium doses' >Alcohol &#8212; Medium doses<\/option><option value='Alcohol -- Low doses' >Alcohol &#8212; Low doses<\/option><option value='Amphetamines, including Aderal and Ritalin' >Amphetamines, including Aderal and Ritalin<\/option><option value='Anti-depressants and Anxiety medication' >Anti-depressants and Anxiety medication<\/option><option value='Anti-Epileptics' >Anti-Epileptics<\/option><option value='Anti-Psychotics' >Anti-Psychotics<\/option><option value='Benzodiazepines, e.g., Valium, Diazepam' >Benzodiazepines, e.g., Valium, Diazepam<\/option><option value='Beta Blockers' >Beta Blockers<\/option><option value='Blood Thinners' >Blood Thinners<\/option><option value='Botox' >Botox<\/option><option value='Bufo, 5-MEO DMT' >Bufo, 5-MEO DMT<\/option><option value='Cannabis Dependency' >Cannabis Dependency<\/option><option value='Cannabis -- High doses' >Cannabis &#8212; High doses<\/option><option value='Cannabis -- Medium doses' >Cannabis &#8212; Medium doses<\/option><option value='Cannabis -- Low doses' >Cannabis &#8212; Low doses<\/option><option value='Cocaine' >Cocaine<\/option><option value='Coca Leaf' >Coca Leaf<\/option><option value='Codeine' >Codeine<\/option><option value='Crack Cocaine' >Crack Cocaine<\/option><option value='Ecstasy (MDMA), Molly or any other MD' >Ecstasy (MDMA), Molly or any other MD<\/option><option value='Fentanyl' >Fentanyl<\/option><option value='GHB' >GHB<\/option><option value='Heroin' >Heroin<\/option><option value='Heroin substitutes -- Methodone, Buprenorphine, Naltrexone' >Heroin substitutes &#8212; Methodone, Buprenorphine, Naltrexone<\/option><option value='High Blood Pressure medication' >High Blood Pressure medication<\/option><option value='Iboga' >Iboga<\/option><option value='Ibogaine' >Ibogaine<\/option><option value='Ketamine' >Ketamine<\/option><option value='Krokodil (Desomorphine)' >Krokodil (Desomorphine)<\/option><option value='LSD' >LSD<\/option><option value='Meth Amphetamine' >Meth Amphetamine<\/option><option value='Morphine \/ Oxycodone' >Morphine \/ Oxycodone<\/option><option value='N, N-DMT' >N, N-DMT<\/option><option value='Nitrous Oxide' >Nitrous Oxide<\/option><option value='Pink (U-47700)' >Pink (U-47700)<\/option><option value='Research chemicals such as: SPICE, Bath Salts, Mephedrone, Synthetic cannabinoids, etc.' >Research chemicals such as: SPICE, Bath Salts, Mephedrone, Synthetic cannabinoids, etc.<\/option><option value='Tramadol' >Tramadol<\/option><option value='Vasoconstrictors (Triptans)' >Vasoconstrictors (Triptans)<\/option><option value='2CB' >2CB<\/option><option value='Not Applicable to me' >Not Applicable to me<\/option><\/select><\/div><\/li><li id=\"field_5_30\"  class=\"gfield gfield--type-multiselect gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\"><label class='gfield_label gform-field-label' for='input_5_30' >Select all of the following conditions that are applicable to you:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple' data-placeholder='Click to select...' size='7' name='input_30[]' id='input_5_30' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='Serious heart disease, heart conditions' >Serious heart disease, heart conditions<\/option><option value='Stroke' >Stroke<\/option><option value='Low blood pressure that is currently medicated' >Low blood pressure that is currently medicated<\/option><option value='Brain hemorrhage' >Brain hemorrhage<\/option><option value='Aneurism' >Aneurism<\/option><option value='Blood clots' >Blood clots<\/option><option value='Serious mental health conditions (discuss with practitioner)' >Serious mental health conditions (discuss with practitioner)<\/option><option value='Chemotherapy or radiation within the past 6 weeks' >Chemotherapy or radiation within the past 6 weeks<\/option><option value='Taking immune suppressants for an organ transplant' >Taking immune suppressants for an organ transplant<\/option><option value='Taking immune suppressants for auto-immune disorders' >Taking immune suppressants for auto-immune disorders<\/option><option value='Addison&#039;s disease' >Addison&#039;s disease<\/option><option value='Recovering from a major surgical procedure' >Recovering from a major surgical procedure<\/option><option value='Current and severe epilepsy' >Current and severe epilepsy<\/option><option value='Currently pregnant or are considering pregnancy' >Currently pregnant or are considering pregnancy<\/option><option value='Breast feeding an infant less than 6 months of age' >Breast feeding an infant less than 6 months of age<\/option><option value='Water fasting for the past 7 days or longer' >Water fasting for the past 7 days or longer<\/option><option value='Detoxing by using colonics or enemas for the past 7 days or longer' >Detoxing by using colonics or enemas for the past 7 days or longer<\/option><option value='Taking slimming, serotonin or sleeping supplements' >Taking slimming, serotonin or sleeping supplements<\/option><option value='Have currently or in the past had a drug or alcohol addiction' >Have currently or in the past had a drug or alcohol addiction<\/option><option value='Not Applicable To Me' >Not Applicable To Me<\/option><\/select><\/div><\/li><li id=\"field_5_53\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\"><label class='gfield_label gform-field-label'  >Have you ever been Bulimic?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_53'>\n\t\t\t<li class='gchoice gchoice_5_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_5_53_0'    \/>\n\t\t\t\t<label for='choice_5_53_0' id='label_5_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_5_53_1'    \/>\n\t\t\t\t<label for='choice_5_53_1' id='label_5_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_34\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\"><label class='gfield_label gform-field-label' for='input_5_34' >Kambo is an intense purge. If you answered &quot;YES&quot; above, please discuss here and we&#039;ll address what is best for you during the consultation portion of your session.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_5_34' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_36\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_5_37\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\"><P>Please understand that Kambo is safe and legal outside of Brazil. <\/P>\n<P>Kambo is an extremely intense physical experience it is NOT hallucinogenic accordingly, you will not have a psychedelic experience or &#8220;trip&#8221; in any way.<\/P>\n<P>I certify and attest that the information provided in this intake for is correct, complete and accurate to the best of my knowledge<\/P><\/li><li id=\"field_5_55\"  class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\"><label class='gfield_label gform-field-label' for='input_5_55' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_55_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' 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