Xanga Ceremony Questionnaire

This questionnaire is designed to help facilitators understand your background, intentions, and any health or safety concerns to ensure a supportive and transformative experience with Xanga.

Name

Last Name

Phone

Emergency Contact Name and Phone Number:

-Intentions and Experience-

What is your primary intention for participating in this Xanga ceremony?

(e.g., spiritual exploration, healing, self-discovery, curiosity, etc.)

Have you participated in a Xanga or DMT ceremony before?

If yes, please describe the experience (setting, dosage, guidance received):

What interests you about Xanga specifically, as opposed to other psychedelic experiences?

Are you seeking to address any specific personal issues or challenges (e.g., trauma, mental health concerns, spiritual blockages)?

How did you hear about this Xanga ceremony?

What are your hopes or expectations from this experience?

-Health History-

Do you have any pre-existing medical conditions (e.g., heart disease, high blood pressure, asthma, epilepsy, etc.)?

10 Have you been diagnosed with any mental health conditions (e.g., depression, anxiety, PTSD, schizophrenia, bipolar disorder)?

If yes, are you currently under the care of a therapist or psychiatrist? Please provide details

Are you currently taking any prescription medications or supplements?

If yes, please list them along with dosages.

Have you ever experienced a psychotic episode or been diagnosed with psychosis?

Do you have a history of addiction or substance abuse?

If yes, please provide details.

Are you pregnant or trying to conceive?

-Substance Use History-

If the previous answer is yes, please provide details (frequency, setting, etc.):

Do you currently use alcohol or recreational drugs?

If yes, please describe frequency and type.

Have you had any allergic reactions or adverse effects from medications or substances in the past?

-Mental and Emotional State-

How would you describe your current mental and emotional well-being?

Are there any recent significant life events (e.g., loss, trauma, personal challenges) that have impacted you emotionally or mentally?

How do you usually handle stress or emotional challenges?

Do you have a support system (e.g., friends, family, therapist) that you can rely on post-ceremony for integration or emotional support?

Have you ever had a difficult or "bad trip" with psychedelics?

If yes, how did you handle it, and what were the circumstances?

-Spiritual Beliefs and Practices-

Do you follow any specific spiritual or religious practices?

If yes, how do these beliefs or practices influence your daily life?

How do you view the role of psychedelics, particularly Xanga, in spiritual development?

Do you have experience with practices such as meditation, breathwork, yoga, or other forms of mindfulness or self-reflection?

-Physical Health-

Do you have any physical health issues or limitations that may affect your ability to sit comfortably or engage with the ceremony?

Are you allergic to any herbs or natural substances?

-Preparation and Informed Consent-

Are you aware of the potential risks of participating in a Xanga ceremony, including possible intense emotional or spiritual experiences?

Yes

Do you understand that this ceremony is not a substitute for professional medical or psychological treatment?

Yes

Are you willing to follow the ceremony guidelines, including any integration or post-ceremony practices suggested by the facilitators?

Yes

Do you consent to share relevant medical or psychological information to ensure your safety during the ceremony?

Yes

-Logistics and Practicalities-

Are you familiar with the setting where the ceremony will take place? If not, do you have any specific concerns about the environment?

Do you have any questions or concerns about the ceremony or its facilitators?

Is there any additional information you’d like to share that would help us create a safer, more supportive experience for you?

Informed Consent for Xanga Ceremony

Introduction 

This document is intended to ensure that you fully understand the nature of the Xanga ceremony you are about to participate in, including the risks, benefits, and responsibilities. It is important that you read this form carefully and ask any questions before signing it. By signing, you indicate that you have been provided with sufficient information and are consenting to voluntarily participate.

1. Nature of the Ceremony

Xanga is a blend of DMT and various smokable herbs, which produces a rapid, intense and very loving psychedelic experience. The ceremony is designed to facilitate spiritual, emotional, and psychological exploration, healing, and growth. It may involve deep introspection, altered states of consciousness, and visionary experiences.

The ceremony will be facilitated by ShaMagic and will follow a set process that includes preparation, the ceremonial experience, and integration. This is a non-clinical, spiritual, and personal growth-oriented experience and is not a substitute for medical or psychological treatment.

2. Potential Benefits

Participants may experience:

Increased spiritual awareness or connection

Emotional healing and personal insights

A sense of unity, connection, or ego dissolution

Relief from certain emotional or mental blockages

Expanded perspectives on life, self, and the universe

However, benefits are highly subjective and not guaranteed.

3. Potential Risks and Side Effects

The Xanga experience can be intense and may involve:

Emotional or psychological experiences, including fear, anxiety, or confusion

Physical sensations such as changes in body temperature

Temporary disorientation, loss of control, or dissociation

Flashbacks or resurfacing of unresolved trauma or suppressed emotions

Increased heart rate, high blood pressure, or stress on the cardiovascular system

The possibility of difficult trips

Changa is not recommended for individuals with certain medical conditions, including but not limited to:

Heart disease or high blood pressure

Epilepsy or seizure disorders

Psychotic disorders or a personal/family history of schizophrenia

Bipolar disorder or severe depression

Pregnancy

4. Responsibilities of the Participant

By signing this consent form, you agree to:

Disclose all relevant medical and psychological information, including current medications, mental health history, and physical conditions, to the facilitators.

Follow any preparatory guidelines provided by the facilitators, including recommended dietary restrictions, meditation practices, or abstinence from substances such as alcohol.

Avoid alcohol or recreational drugs for at least 48 hours before and after the ceremony.

Follow all instructions given by the facilitator before, during, and after the ceremony.

Approach the ceremony with respect, openness, and a commitment to personal growth.

Engage in the integration process post-ceremony, such as reflecting on your experience and seeking support if needed.

5. Confidentiality

All information you share during the ceremony, including personal insights, experiences, and health information, will be treated as confidential. The facilitators will not share any of your personal information without your explicit consent, except where required by law (e.g., in cases of harm to self or others).

6. Limitations and Disclaimer

This Xanga ceremony is not a form of therapy, nor is it intended to replace professional medical, psychiatric, or psychological treatment. While the facilitators are committed to providing a safe and supportive environment, the outcome of the experience cannot be predicted or guaranteed.

You acknowledge that:

You are voluntarily participating in this ceremony.

You accept full responsibility for any emotional, psychological, or physical reactions you may have during and after the experience.

The facilitators are not liable for any adverse effects, injuries, or complications that may arise as a result of participating in the ceremony.

7. Emergency Protocol

In the unlikely event of a medical emergency, the facilitators will take appropriate steps to ensure your safety. This may involve pausing the ceremony, providing first aid, or contacting emergency medical services. It is essential that you provide accurate information regarding your health to ensure proper care is available if needed.

8. Acknowledgment of Understanding

By signing below, you acknowledge that:

You have read and fully understood the information provided in this document.

You have had the opportunity to ask questions and receive satisfactory answers regarding the nature of the ceremony, its risks, and its benefits.

You understand the potential risks, side effects, and responsibilities associated with participating in a Changa ceremony.

You freely and voluntarily consent to participate in the Changa ceremony.*

This informed consent form is designed to protect both participants and facilitators by ensuring all parties are aware of the expectations, risks, and responsibilities involved in a Changa ceremony.

I accept

I don't accept

Your full name

Today's date

Month

Day

Year

SHAMAGIC