PAIP Therapy Registration 
  • Psychedelic Assisted Integration Psychotherapy (PAIP) 2024

    Psychedelic Assisted Integration Psychotherapy (PAIP) 2024

    Official Registration Form

  • Welcome.

    Please be aware that there is a £250 (non-refundable) holding deposit to pay at the end of this form as we expect anyone completing the form to be sure they want to attend one of our events. In general, you will have had a brief conversation with Shaura to discuss your engagement with PAIP, including a plan for accessing the work.

    Contact shaura@theyogologist.co.uk if you would like to discuss the above.

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  • Are you currently taking any regular medications?*
  • Do you currently use any recreational drugs, narcotics, or used plant medicines of any kind?*

  • Previous Psychedelic Use

  • Have you taken a psychedelic substance in the last 90 days?*

  • Previous Psychedelic Use

  •  - -
  • Do you intend to take a psychedelic substance between now and your desired PAIP session(s)?*

  • Personal History

  • The following questions are specifically intended to help us understand what you are working through in life: your psychological history, childhood experiences, past trauma, and current mental health.

    Our framework is from a questionnaire that measures adverse childhood experiences (ACE) and indicates whether your system has been subject to toxic stress. Your answers will help to know if PAIP is safe for you to undergo now.

    This information is held confidentially and used solely to assess how we may best support you therapeutically. If you need more time to prepare, we will offer you a course of therapy, either with one of our facilitators or another of our trained Integration Psychotherapists.

    Please click 'next' if you would like to proceed...

  • Experiences of Trauma

  • Have you ever experienced, witnessed, or been repeatedly confronted with any of the following: (Check all that apply)
  • If you marked any of the above items, which single traumatic experience is on your mind and currently bothers you the most: (Check only one)

  • Childhood Experiences

    While you were growing up, during your first 18 years of life...
  • Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?*
  • Did a parent or other adult in the household often push, grab, slap throw something at you? Or ever hit you so hard that you had marks or were injured?*
  • Did an adult or person at least 5 years older than you ever touch or fondle you, or have you touch their body in a sexual way?*
  • Did you often feel that no one in your family loved you or thought you were important or special? Or your family didn’t look out for each other, feel close to each other, or support each other?*
  • Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?*
  • Were your parents ever separated or divorced?*
  • Did you experience the death of parent or primary care giver?*
  • Were your parents, or any of your primary caregivers often pushed, grabbed, slapped, or had something thrown at them? Or kicked, bitten, hit with a fist, or hit with something hard? Or ever hit repeatedly hit over at least a few minutes or threatened with a gun or knife?*
  • Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*
  • Was a household member depressed or mentally ill or did a household member attempt suicide?*
  • Did a household member go to prison?*

  • Psychological Experiences of Self

  • Psychological Experiences of Self

    Has there ever been a period of time when you were not your usual self and...
  • ...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?*
  • ...you felt much more self-confident than usual?*
  • ...you got much less sleep than usual and found you didn’t really miss it?*
  • ...you were much more talkative or spoke faster than usual?*
  • ...thoughts raced through your head or you couldn’t slow your mind down?*
  • ...you were so easily distracted by things around you that you had trouble concentrating or staying on track?*
  • ...you had much more energy than usual?*
  • ...you were much more active or did many more things than usual?*
  • ...you were much more social or outgoing than usual, for example, youtelephoned friends in the middle of the night?*
  • ...you were much more interested in sex than usual?*
  • ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?*
  • ...spending money got you or your family in trouble?*
  • If you checked yes to any of the above questions, have several of these ever happened during the same period of time?*
  • How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights?*
  • Have any of your blood relatives (i.e., children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?*
  • Has a health professional ever told you that you may have manic-depressive illness or bipolar disorder?*
  • Has anyone in your family ever experienced psychosis or been diagnosed with schizophrenia?*
  • Have you ever experienced or felt afraid that you might be experiencing psychosis?*
  • Are you currently in therapy?*

  • For those currently on medication(s) or using recreational drugs, we strongly advise you to speak to your GP or Psychiatrist before booking your place.

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  • Rows
  • For Retreats only -please select any dietary restrictions you may have
  • Do you know anyone who works with the Yogologist or with Integration Psychotherapy?*
  • How did you hear about PAIP with the Yogologist?*
  • Do you have any questions you'd like to be contacted to discuss?*

  • Please read the following terms and conditions carefully before proceeding:


    By signing below and submitting this form, you are confirming that all of the information you have disclosed in this document is accurate to the best of your knowledge and belief, and was provided without any misleading or malicious intent. You also agree to participate in a Deep Work Therapy, which offers therapeutic facilitation and integrative support within a PAIP framework, where any psychedelic substances you may choose to consume during your PAIP session(s), will be provided and consumed by you for therapeutic purposes. By signing and submitting this form, you are confirming that you understand and agree to the following terms:

    • I agree to participate in PAIP sessions which offer therapeutic facilitation and integrative support within a PAIP framework, where any psychedelic substances I may choose to consume during PAIP ceremonies, will be provided and consumed by me for therapeutic purposes;

    • I understand that I am registering to participate in ceremonies held within a PAIP framework and am aware that this is not a recreational activity in any sense, as PAIP session(s) are inherently therapeutic in nature and may give rise to potentially uncomfortable, unpleasant, or otherwise challenging experiences, regardless I agree to follow the rules of the PAIP session(s) at all times;

    • The cost of PAIP goes towards the safe and professional facilitation of PAIP session(s) and is thus non-negotiable, nor can any fees be refunded under any circumstances;

    • I understand that PAIP facilitators are trained in the appropriate facilitation and safeguarding procedures and will take any steps necessary to ensure all PAIP ceremonies and subsequent integration sessions are carried out safely and reasonably;

    • I understand that I am personally responsible for my own health and safety before, during, and after any PAIP ceremonies to a reasonable extent, and I should consult with my GP, psychiatrist, or a qualified medical professional prior if I am at all concerned about any risks posed to my physical or mental health by my taking part in PAIP;

    • I understand that I may be financially liable for any damages to the venue or surrounding property, as well as any potential harm to facilitators and or other clients/participants brought about by my actions at any point before, during, or after any PAIP sessions;

  • Please confirm that you have read and agree to the terms and conditions outlined in this form.*
  •  - -
  • Are you submitting the non-refundable deposit through this form?
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    Holding Deposit Product Image
    Holding Deposit

    PAIP Therapy

    £250.00
      
    Total
    £0.00
    Credit Card Details
  • I need to submit my payment by a different method.

  • Bank Transfer 

    Account Name: Shaura Hall (Business)

    Account Number: 78685554 

    Sort Code: 608371 

    IBAN: GB48SRLG60837178685554 

    SWIFT/BIC: SRLGGB2L 

    PayPal 

    https://www.paypal.com/ncp/payment/FKFCSJJBNM5P8

     

     

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