Medical Intake form

INITIAL INTAKE FORM

Kindly complete & submit prior to your therapy session. You will see a GREEN CHECKMARK AND THANK YOU message upon successful completion. If you do not see a green check mark after completing the form, you have left a mandatory field blank. Recheck your answers to ensure all mandatory fields are answered. Please be sure to NOT LEAVE THIS PAGE as the form will auto delete for privacy protection after a certain time.

All information is kept 256-bit encrypted and is confidential in compliance with HIPAA. Thank you.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Date of Birth*

Date

Place of Birth

City/State or Town/Country if not in the US

Gender*

Marital Status

Primary Physician *

Primary Physician Phone

Current Therapist

Current Therapist Phone

Emergency Contact *

Emergency Contact Phone *

What is your main presenting issue?*

0/200

About when did this start?

Date

Have you previously suffered with this issue?

YesNo

Previous treatment(s) for this issue?

0/60

What was the result?

Aggravating factors*

0/60

Relieving factors*

0/60

Please list any previous psychological diagnosis (ie PTSD, MDD, ADHD, OCD, etc):

Please list any other significant physical or psychological trauma you've experienced:

Do you have any history of or current heart conditions?*

YesNo

If yes, please list.

0/60

If yes, please list.

0/60

Do you have any allergies?

YesNo

If yes, please list.

0/60

What medications / plant medicines are you currently using?*

Previous diagnosis / mental health treatment:

Previous medical conditions:

Previous surgeries:

Exercise Frequency

Who raised you as a child?

Were you adopted?

How was/is your relationship with your mother?

How was/is your relationship with your father?

Siblings and their ages:

Have any immediate family members died recently?

If yes, who?

Have any family members commited suicide?

If yes, who?

Where did you grow up?

How often did you move and where?

How old were you when you left home?

Describe any neglect you suffered, and by whom:

Highest education level completed:

Have you ever served in the military?

If yes, when and where?

Work Status:*

Are you married?

Sexual Orientation

Do you have children?

How is your relationship with them?

List anyone else who lives with you:

Are you a member of a religious or spiritual group?

What is your level of involvement?

Have you ever been arrested? *

If yes, when and why?

Please check all that apply:

	Currently	Past Use	Rarely Used
Alcohol
Heroin
Stimulats (Pills)
Tobacco
Methamphetamines
Methadone
Pain Killers
Cocaine
Tranquilizers

Have you ever been treated for drug or alcohol abuse?*

If yes, when and for what substane(s)?

Please check all that apply:

	Currently	Past Use	Rarely Used
Ayahuasca
Psilocybin Mushrooms
Cannabis
Ketamine
Peyote or Cactus
MDMA
Sassafras
LSD
5-MEO-DMT
N-N DMT
Other

What insights have come from your experiences with any of the above?

What challenges have come from your experiences with any of the above?

What do you feel still needs integrating or assimilating from these experiences?

If yes, please list.

How would you like to conduct our sessions?*

PhoneVideo Zoom CallIn Person (where applicable)

How often would you like to have a session?*

BiweeklyMonthlyAs needed

Who referred you:*

Signature

Please verify that you are human*

You also understand and agree that you are fully responsible for your own well-being during your coaching and therapy sessions, and subsequently, your choices and decisions.All information in this document will be kept encrypted and confidential with the exception of the client being of immediate harm to self or someone else. A written consent is needed from you, the client in order for the treatment provider be allowed to release any other information. Confidentiality applies to any notes or treatment plans devised in therapy. Additionally, you hereby release, waive, acquit and forever discharge your therapist from every claim, suit action, demand or right to compensation for damages claimed or that you may have arising out of your own acts or omissions or acts and omissions of your therapist as a result of any advice given otherwise resulting from the therapeutic relationship contemplated by this agreement. You further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made. Integrate with Erik and your therapist reserve the right to refuse access to the service. For all international clients, all therapy and counselling services are undertaken in accordance with the laws of the practitioner's own country and any disputes will be subject to that country's law.

PERSONAL INFORMATION

PRESENTING ISSUE

CURRENT SYMPTOMS

MEDICAL HISTORY

FAMILY HISTORY

EARLY DEVELOPMENT

PRESENT SITUATION

HAVE YOU EVER TRIED THE FOLLOWING:

ENTHEOGENIC EXPERIENCES & USE:

ANYTHING ELSE YOU WANT YOUR CARE PROVIDER TO KNOW

SESSION DETAILS