Ceremonial Hapé Questionnaire Name * First Name Last Name Email * Date of Birth * MM DD YYYY Have you experienced Hapé before? Yes No What are you currently seeking support with? (emotional, spiritual, physical, energetic, etc.) Are you comfortable with the physical administration of Hapé? Hapé is served by blowing into each nostril via a pipe known as a tepi. Yes No Do you have any current or chronic health conditions? Yes No Are you currently taking any medications, supplements, or herbal remedies? Yes No Do you have a history of the following? Check all that apply. Heart conditions High or low blood pressure Respiratory issues (asthma, COPD, etc.) Neurological conditions (seizures, epilepsy, etc.) Mental health diagnoses (depression, anxiety, PTSD, etc.) Substance dependency Other Are you pregnant, breastfeeding, or trying to conceive? Yes No Do you have any allergies or sensitivities (smoke, herbs, plants, etc.) Yes No Is there anything else you wish to share that would help me better hold space for you? Disclaimer * I understand that Hapé is a traditional Amazonian herbal snuff, typically made from Nicotiana rustica (sacred tobacco) combined with ashes and medicinal plants. It is traditionally used for grounding, clearing, and connecting with spirit. I acknowledge that this practice is spiritual and energetic in nature and not a substitute for medical care. I release the facilitator from any liability for adverse reactions, and I take full responsibility for my participation. I understand and agree Thank you!
