Basic Information
The questions in this section will gather some basic information about you
Name
*
First Name
Middle Name
Last Name
E-mail
*
Contact Number
Age
*
Gender
Please Select
Male
Female
Other
Height (inches)
Weight (pounds)
Health History
The questions in this section will gather information about your mental and physical health
Are you allergic to anything?
*
Have you ever been diagnosed or suspect you have any of the following medical conditions?
*
High blood pressure
Heart attack
Heart arrhythmia
Stroke
Heart failure
Coronary artery disease
Chest pain or angina
Epilepsy or seizure disorder
Current Pregnant or Breastfeeding
Liver or kidney failure
Cancer
Diabetes
Asthma or COPD
Traumatic Brain Injury
None of the above
Do you take medication for any of the above?
Do you have any other condition(s)?
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?
*
Depression
Anxiety
Post Traumatic Stress Disorder (PTSD)
Substance Use Disorder or Addiction
Obsessive Compulsive Disorder (OCD)
Schizophrenia or other psychotic condition
Bipolar disorder
Personality disorder
None of the above
Other
Description of psychiatric condition(s)
Have you ever been hospitalized for a psychiatric reason?
Do you have suicidal thoughts or have you made a suicide attempt?
Do you currently use any prescription medication? If so, please list.
Other OTC medication, supplements, and/or herbal products?
Have you used any of the following substances in the past 3 months?
*
Cocaine
Methamphetamine
Heroin or non-prescription opioids
Alcohol
Inhaled nitrates
GHB
Cannabis
None of the above
Other
Description of use of above selected:
What medicine(s) are you interested in working with? Check all that apply.
*
Psilocybin
Kambo
LSD
5-Meo-DMT
2C-B
Hapè
DMT
MDMA
Mescaline
Integration
Other
What are your goals for psychedelic work? Check all that apply
*
Soul Quest
Trauma Resolution/Shadow Work
Past Life Experiences
Akashic Records Access
Bond with Family/Friends
Reflection on current life/relationships
Recreation in a safe setting
Other
Description of Any Past Psychedelic Use - include dosages where known
*
Intention for Psychedelic Use
*
Desired Outcomes from Psychedelic Use
*
Do you currently have any spiritual/meditative/centering practices?
*
Meditation
Prayer
Yoga
Journaling
Art therapy
Mantra
Breathwork
Other
Current faith or religion?
*
Questions or topics for discussion
Social History and Support Network
The following questions will help understand more about your current social situation and support network
Which of the following describes your current relationship status?
*
Single
Married
Married with Children
Separated or Divorced
Widowed
Other
Which of the following best describes your work situation?
*
Unable to work due to disability
Not working by choice
Unemployed or underemployed
Student or education program
Part time
Full time
Retired
Other
Are there any major sources of stress in your life at the moment or events that have occurred recently that have impacted your health?
Which of the following do you consider your support network?
*
Therapist or Counselor
Psychedelic Integration Coach
Psychiatrist or Provider
Alternative Practitioner
Partner or Family Members
Close Friends
Psychedelic Society
Church or Religious Organization
Treatment Program
Other
Current Symptoms
The following questions are designed to create a snapshot of how you've been feeling over the last 2-4 weeks
Survey of Depression Symptoms
*
Not at all
Several Days
More than half of days
Almost every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
Survey of Anxious Symptoms
*
Not at all
Some of the days
More than half of days
Almost every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Stressful Life Experience and Trauma Symptoms
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Feeling very upset when something reminded you of a stressful experience from the past?
Avoided activities or situations because they reminded you of a stressful experience from the past?
Feeling irritable or having angry outbursts?
Feeling jumpy or easily startled?
Other questions/concerns to address before scheduled session.
Save
Submit
Should be Empty: