Bella Vida Chapel Intake Form

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.