Legal Name *

First Name

Last Name

Spiritual / Preferred Name Use

First Name

Last Name

Birth Date

MM

DD

YYYY

Phone Number *

Country Code is for phone numbers outside U.S. U.S. numbers start with second box

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Number *

Country Code is for phone numbers outside U.S. U.S. numbers start with second box

Country

(###)

###

####

Program Selection *

UBSA Spiritual Self Development Phase I

Ukuthwasa Sangoma Initiation

Graduate Priest Extended Learning

Spiritual Training (uncertain of my path)

Ancestral Healing

I have received a divination from Yeye Gogo Nana *

Yes

No

I have received a divination from a graduate Sangoma of UBSA *

Yes

No

I have been through initiation led by an Earth Teacher *

Earth teacher means an actual physical Spiritual Teacher who initiated you into a particular path where you became an ordained Traditional / Indigenous Healer.

Yes

No

I have been through spiritual initiations led by Spirit Beings *

Spirit Beings are invisible and sometimes visible beings who come and take you for a period of time and initiate you into a particular spiritual path.

Yes

No

I have been initiated into a spiritual path but did not complete *

Yes

No

At some point I was hospitalized for health reasons *

Yes

No

I have been diagnosed with physical health issue.

Yes

No

I have been diagnosed with a mental health issue. *

Yes

No

I am currently under a medical doctor's care *

Yes

No

I am currently taking prescription drugs. *

Yes

No

I am currently self medicating. *

Yes

No

I am familiar with African Traditional Healing Systems *

Yes

No

I have experience with Shamanic Healing /Journey *

Yes

No

Gender *

Please has honestly this will help us to better serve your spirit.

Male (born male)

Female (born female)

Other Gender Identity (if chosen, please state below)

I know someone who has graduated, currently training, taking course work, or has had spiritual healing services performed by a Priest of UBSA *

Yes

No

I feel I have a shamanic calling. *

Yes

No

I have had spiritual reading/s divination/s by other healers *

Yes

No

Preferred Method of Contact *

Phone

Email

Best Time To Contact You By Phone *

Hour

Minute

Second

AM PM