Bella Vida Chapel Intake Form

Ceremony Intake

Complete the questionnaire to participate in a BVC ceremony. Please do not fill out this form until you are ready to commit to a ceremony date and make a donation to hold your space or for sacraments. If you have questions please send them through the contact us page.

First Name

Last Name

Phone

Street Address

City

State

Zip code

Birthdate

What sacrament are you interested in?

Why do you want to attend a BVC ceremony? *

Have you ever utilized sacraments? If so, what have you utilized?

Do you have allergies to foods or medications? If so, list them here.

Do you have any medical conditions? If so, list them here. *

Do you have any mental health conditions? If so, list them here.

Have you been hospitalized for a physical or mental illness in the past 24 months? If so, provide details here.

Are you currently suicidal, homicidal, or experiencing visual or auditory hallucinations? If so, provide details here.

Are you currently on medications? If so, list the medications, dosage and reasons why they were prescribed here.

If there is anything else you would like us to know, provide details here.

Who referred you to Bella Vida Chapel?

How often do you drink alcohol?

What dates would you like to attend ceremonies?

How would you like to submit donation?

Credit Card

Cashapp

Zelle

Mail cash, check or money order