Aunt Tara's Farm - Intake Questionnaire

Basic Information

The questions in this section will gather some basic information about you
Name*

First NameMiddle NameLast Name
E-mail*
Contact Number
Age*
Gender
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 pressureLow blood pressureHeart attackHeart arrhythmiaStrokeHeart failureCoronary artery diseaseChest pain or anginaEpilepsy or seizure disorderCurrent Pregnant or BreastfeedingLiver or kidney failureCancerDiabetesAsthma or COPDTraumatic Brain InjuryNone 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?*

DepressionAnxietyPost Traumatic Stress Disorder (PTSD)Substance Use Disorder or AddictionObsessive Compulsive Disorder (OCD)Schizophrenia or other psychotic conditionBipolar disorderPersonality disorderNone of the aboveOther
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?*

CocaineMethamphetamineHeroin or non-prescription opioidsAlcoholInhaled nitratesGHBKetamineCannabisNone of the aboveOther
Description of use of above selected:
What medicine(s) are you interested in working with? Check all that apply.*

PsilocybinKamboLSDBufo Alvarius (5-Meo-DMT)2C-BHapèDMTMDMAMescalineIntegrationOther
What are your goals for psychedelic work? Check all that apply*

Soul QuestTrauma Resolution/Shadow WorkPast Life ExperiencesSpiritual AwakeningBond with Family/FriendsReflection on current life/relationshipsRecreation in a safe settingOther
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? *

MeditationPrayerYogaJournalingArt therapyMantraBreathworkOther
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?*

SingleMarriedMarried with ChildrenSeparated or DivorcedWidowedOther
Which of the following best describes your work situation?*

Unable to work due to disabilityNot working by choiceUnemployed or underemployedStudent or education programPart timeFull timeRetiredOther
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 CounselorPsychedelic Integration CoachPsychiatrist or ProviderAlternative PractitionerPartner or Family MembersClose FriendsPsychedelic SocietyChurch or Religious OrganizationTreatment ProgramOther
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.
Should be Empty:

Basic Information

Health History

Social History and Support Network

Current Symptoms