Rapé & Sananga Intake Form · Primal Coherence

Section 1 — What you're receiving

Rapé and Sananga are offered together as one ceremony. You are welcome to opt out of either. Please indicate below what you are consenting to receive:

Both Rapé and Sananga Rapé only Sananga only

Section 2 — Rapé

Rapé (pronounced ha-PAY) is a sacred powdered medicine made from Mapacho — a potent heirloom Amazonian tobacco — combined with the ashes of sacred trees and medicinal plants. It is administered through the nostrils using a tepi pipe. The experience is immediate and intense: a forceful clearing sensation that moves through the sinuses, quiets the mind, and commands full presence.

Rapé contains Nicotiana rustica — a form of tobacco significantly stronger than commercial tobacco. Please disclose any relevant health conditions before your session.

Rapé is not suitable if any of the following apply:

Severe cardiovascular conditions or high blood pressure
First trimester pregnancy
Significant sensitivity to nicotine — please communicate this in advance
Current respiratory infection or severe sinus congestion

I have read the information above about Rapé, understand what it involves, and confirm that none of the contraindications listed apply to me. I consent to receiving Rapé. (Leave unchecked if opting out.)

Section 3 — Sananga

Sananga comes from the Tabernaemontana plant family, native to the Amazon rainforest. It is administered as drops into each eye. The burning sensation is immediate and intense — spreading from the eyes through the face and sometimes the whole body. Most people move through the peak within five to ten minutes. What follows is a deep clarity, sharpness, and sense that something unnecessary has been washed away.

The burning is temporary and leaves no lasting physical effect. Tears flow freely — this is part of the medicine.

Sananga is not suitable if any of the following apply:

Acute eye infections or recent eye surgery
Detached retina
Extreme light sensitivity — please mention this in advance
Active eye disease or condition affecting the cornea

I have read the information above about Sananga, understand what it involves including the intensity of the experience, and confirm that none of the contraindications listed apply to me. I consent to receiving Sananga. (Leave unchecked if opting out.)

Section 4 — General consent & liability

By completing this form you confirm that you are voluntarily participating in a Rapé and/or Sananga ceremony at Primal Coherence. You understand that your practitioner, Jane Savina, is not a licensed medical professional and is not providing medical diagnosis, treatment, or advice. These are sacred plant medicines administered in a ceremonial context. You release Primal Coherence and Jane Savina from any liability related to physical or emotional discomfort during or after the ceremony.

You may ask to stop at any time and your practitioner will immediately honor this.

I voluntarily consent to this ceremony, I understand the nature of these medicines, and I release my practitioner from liability related to physical or emotional discomfort during or after the session.

Section 5 — Health intake

Please check any of the following that apply to you:

Pregnancy
Heart condition / high blood pressure
Eye condition or recent eye surgery
Sensitivity to nicotine or tobacco
Currently taking medications
Other health condition

If you checked any of the above, please provide more detail

Your information

Full name *

Date of birth *

Phone *

Have you worked with Rapé or Sananga before?

What brings you to this ceremony?

Electronic signature

By typing your full name below, you are signing this document electronically. You confirm that you have read all sections of this form, that the information provided is accurate and complete to the best of your knowledge, and that you are voluntarily consenting to receive the ceremonies you have selected above.

Type your full name to sign *

Date signed *

By checking here, I consent to the use of my electronic signature in lieu of an original signature on paper. I confirm all information provided is accurate and complete to the best of my knowledge.

Your submission is sent securely to your practitioner.
Questions? Text (443) 254-6762.

Intake form received 🌿

Thank you for completing your intake form. Jane will review it before your ceremony.
Questions? Text (443) 254-6762.