Shamanic Healing Questionnaire

One of the on-going projects in the FSS Shamanism and Health Program is to collect, study, and archive reports of healing and cures following shamanic treatment of physical, emotional, and mental disorders.

Your report can make a difference in our understanding of these phenomena. As research progresses we expect to share the results of these findings for the benefit of those seeking and offering shamanic treatment.

If you have experienced such a miracle or have done shamanic healing work with positive results for another, please take the opportunity to complete the form below now. Complete what you can. Anything will be useful.

Please be certain you have consent to disclose the name and other personal information about those for whom you have worked as a shamanic practitioner, if you include such information. Your report will be kept confidential. It is for the use of the research staff only.

Thank you for your willingness to contribute to this valuable resource.

Note: This Questionnaire is not for those seeking shamanic healing. If you are seeking shamanic healing, please refer to the Shamanic Services Listings for a list of FSS members engaged in shamanic healing/divination practices in your area. (FSS offers this service to its members and to the public, but cannot endorse or guarantee the work of any of its members offering shamanic healing.)

Shamanic Healing Synchronous Remission Questionnaire

(Please Use A Separate Form For Each Treatment)

Shamanic Healing Session No.

1. Submitted By  
Zip/Postal Code:
E-mail Address: 

2. May we contact you for further information? Yes No

3. Person doing shamanic work:
How experienced was he/she at doing shamanic healing work:
Not at all Slightly Very

4. Person receiving shamanic work:  (Be sure you have consent to disclose this information.)
Zip / Postal Code:
Date of birth: Sex: Female Male

5. Was client familiar with shamanism prior to this experience?
Not at all Somewhat Very experienced at journeying

6. Nature of condition in ordinary reality:

7. Duration of symptoms:
Under 1 year Under 5 years Over 5 years

8. The ordinary reality diagnosis was made by:
MD Psychiatrist Psychologist Physical Therapist
DO Chiropractor Other (please indicate)

9. Date of initial visit or diagnosis: 

10. Treatment prescribed:
Medication Surgery Physical Therapy
Psychotherapy Other (please indicate)
Did client comply with treatment? Yes No

11. Length of treatment in ordinary reality:
Date of initial treatment: 
Date of last treatment:    

12. Was the ordinary reality treatment effective? Yes No
Please give details:

13. Were there 2 or more shamanic sessions for this condition? Yes No
Please elaborate:

14. Was the shamanic work done on behalf of self? Yes No

15. How many times was shamanic work done for this symptom?

16. Type of healing:
Shamanic Practitioner Alone Spirit Canoe Shamanic Healing Circle
Direct Healing:
Retrieval and/or merger with a power animal:
Healing from power animal:
Healing from teacher:
Receiving of power or healing object:
Soul retrieval:
Power animal retrieval:
Information and/or Instruction
From power animal
From teacher
Was client: Present Long distance
Please describe any experiences of the client during journey/shamanic work. If none, enter "none."
Were there any synchronicities between client and shamanic practitioner in the context of the journey/healing work?

17. Did healing occur in the:   Upper World Middle World Lower World

18. Was drumming used?   Yes No
If yes, drumming was:   Live Recorded

19. Was other sonic input used?   Yes No
If yes, please describe:

20. Describe journey (if used) briefly as it relates to healing.

21. Were effects felt:   Immediately afterwards Later (specify below)
Please describe:

22. Were the effects long term?   Yes No

23. Did any non-shamanic health professional make a statement that the condition was:
In remission Cured

24. Were any other conditions affected?   Yes No
Please describe:

25. Did client's lifestyle or behavior change?  Describe:

26. Were there any recurrences?   Yes No

27. Please provide any additional observations or comments

28. Anti-Robot Test
What kind of fruit do you see (Click here to hear it read aloud.)
Hint: It rhymes with “snapple”.