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Spirit Pharmacist Psychedelic Experience Intake Form

Please complete the following form as completely and truthfully as possible. This form is an example template that may be used to screen persons prior to considering therapeutic work with psychedelics. It was created for informational and educational purposes. It is not intended to be used verbatim, as medical advice, or to condone illicit activities. 
45Questions

HIPAA

Compliance

  • 1
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  • 2
    You must supply a working email address for consultation service
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  • 3
    Please complete with phone number including area code
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  • 5
    • Male
    • Female
    • Non-binary
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  • 8
    Please provide a description of the allergy or intolerance as well as reaction you have below. Type N/A if you're not allergic to anything.
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  • 9
    Please select all that apply and describe further in the next page of the form
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  • 11
    Please use this space to FURTHER DESCRIBE medical conditions from the previous page. Information on how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc. is welcome.
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  • 12
    Please select all that apply and describe further below. f you do not have any of the psychiatric conditions listed please select 'none of the above'.
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  • 13
    Pleas use this space to describe any psychiatric condition you have further here
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  • 14
    If yes please describe further below
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  • 16
    If yes please describe further below
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  • 21
    Please include a complete list of your prescription medications including the drug NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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  • 22
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  • 23
    Please include a complete list of your OTC medication, supplements, and herbal products including the NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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  • 24
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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  • 25
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  • 26
    Please select the option that most closely matches your use
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  • 28
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  • 29
    What kind of tobacco product to you use? how often? for how long?
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  • 30
    If you have not used any please mark 'none of the above'
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  • 31
    How much of each substance? How often? Any additional commentary you wish to offer.
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  • 32
    Psilocybin mushrooms, LSD, ayahuasca, DMT, MDMA, ketamine, ibogaine, mescaline etc.
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  • 33
    Please describe the use and experiences with previous psychedelics.
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  • 34
    Please describe why you would like to undergo a psychedelic experience including why you want to use any specific psychedelic and why you feel using it at this point in your life would be beneficial?
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  • 35
    Please describe what you are hoping to receive from psychedelic use: How will you feel or act afterwards that is different than now?
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  • 36
    Please use this space to type any specific questions you may have about current medications or substances you're taking or about psychedelics you're interested in or plan to take.
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  • 37
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  • 39
    E.g. Workplace struggles? Toxic relationships? Death of persons close to you? Change in health status? Ongoing stressors? etc.
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  • 40
    Please select all options you use for support of your health needs.
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  • 41
    Please complete the following questions based upon how you've been feeling over the past 2 weeks
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  • 42
    Please complete the following questions based upon how you've been feeling over the past 2 weeks
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  • 43
    Please indicate how much you have been bothered by each problem in the past month
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  • 44
    Use this space to describe anything you feel is important for us to know about you
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  • 45
    By checking the box below you are verifying to have read and agree to the linked terms and conditions
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