Screening form / 5MeO-DMT

Screening form

for you sacred ceremony
Welcome

Dear participant. Welcome to the next step of your journey. We kindly ask you to fill in this form to the best of your ability. We recommend that you give your self time and space to carefully read through this application form and answer thoroughly.
Information

Please read the following carefully, as it describes any risks that may be associated with consuming 5MeO-DMT. If there is any part of this form that you do not understand please contact the Organizer before completing the Questionnaire. The Questionnaire asks questions that may be sensitive in nature. All information on this form will be kept confidential unless it is used for medical and/or legal purposes. Please fill out the form to the best of your knowledge.

Reason for attending ceremony: Do you have any specific intention or agenda?
Write in your own words

Name

First NameLast Name
Gender Identity
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
BMI Index
Emergency contact, full name & tel phone nr
Relation of emergency contact
Does this person know that you will be receiving 5MeO-DMT?

Participant Psychological History
History of hospitalization: Have you ever been seen in a psychiatric emergency or been hospitalized for having a break of any kind? If so, when was it, and for how long? Have you ever been court-ordered to work with a psychiatrist or psychologist? If yes, what was the circumstance?
History of Medication: Have you ever been prescribed medication to manage yourpsychological state? If yes, then which medications and for how long? Why did you discontinue using them?
History of Schizophrenia: Have you ever been diagnosed with schizophrenia or schizoaffective? Have you ever had an episode that seemed schizophrenic in nature? Is there anyone in you immediate family with schizophrenia?
History of Bipolar Disorder: Have you ever been diagnosed with bipolar disorder? If yes, when was the diagnosis?
History of Borderline Personality Disorder: Have you ever been diagnosed with a borderline disorder? If yes, when was the diagnosis?
History of Mania or Psychosis: Do you have a history of mania or psychosis? If yes, when was the diagnosis? Has anyone in you immediate family been diagnosed with mania or psychosis?
History of Narcissistic Personality Disorder: Have you ever been diagnosed with a narcissistic personality disorder?
Depression history: Are you currently experiencing depression? If so, how severe and for how long? Have you been seeing a mental health professional to help with your depression? What do you think is causing the depression? Have you experienced depression in the past? If so, then how severe and for how long? Have you ever taken medication for depression or been advised to take medication for depression?
Anxiety history: Are you currently experiencing anxiety? If so, how severe and for how long? Have you been seeing a mental health professional to with your anxiety? What do you feel is causing the anxiety? Have you experienced anxiety in the past? If so, then how severe and for how long? Have you ever taken medication for anxiety or been advised to take anxiety medication ?
Suicide history: Are you currently suicidal? Have you ever attempted suicide before? Have you ever had suicidal thoughts? If yes, then when and for how long?
Traumatic history: Later in the form we provide an in-depth questioner on trauma
How would you describe your current state of mental health?

Psychedelics, Drugs & Alcohol History
5-MeO-DMT: Have you ever worked with 5-MeO-DMT/Bufo secretion before? If yes, what was your experience like? Did you have any challenges? Did you have any adverse reactions? Why are you choosing to work with 5-MeO-DMT as opposed to other medicines?
Psychedelics: Which psychedelics (cannabis included), if any, have you worked with? Do you know your doses? Have you ever had a negative reaction to a psychedelic before? If yes, which psychedelic and what happened? Did you have any difficulty integrating after any psychedelic sessions?
Drugs: Do you currently use any drugs such as opiates (including tramadol, Tapentadol,methadone, and meperidine), crack, cocaine, fentanyl, methamphetamine, or any other drugs?If yes, how often and for how long? Have you used any drugs in the past, either single use orrecreationally?
Alcohol: Have you ever been diagnosed, treated or self-identified with alcohol use disorder? If yes, please provide additional information about your experience. If you consume alcohol please provide information on frequency and quantity

Personal History

With this section of the screening form we ask you to share with us your personal story to help us build the right container for you and to determine if any additional support or skillset are needed.
Current relationship status: Are you in a relationship with a significant other? Do you have children?
Home: What is your current living conditions? Where did you grow up? Who was in your family growing up? Are your parents separated/ divorced/ other?
Caregiver: Are you a primary caregiver today? Who was your primary caregiver as a child? Who picked you up from school, made lunches/ dinners, took you to activities, etc?
Father: What was your fathers parenting style?
Mother: What was your mothers parenting style?
Safety: Who would you seek comfort from if you were upset as a child?
Major life events: Please summarize all major life events and/or major transitions including abuse, loss, grief, transfers, career changes, spiritual awakening etc (repeated given information is welcome)

Participant Trauma History
Have you experienced or been witness to a traumatic event? Can you describe what happened?
How has this traumatic experience affected you? Do you have flashbacks, nightmares, or fear that arises due to the event?
What emotions, if any, came up as a response to the trauma?
How mild, moderate, or severe would you say your trauma is? Does the trauma still have you in a raw and vulnerable place at this moment in your life?
Have you ever reached out for professional mental health support to process the trauma? Has it been supportive?
Are there any words, language, sounds, songs, touch, gender, or anything else that you are aware of that triggers the trauma for you?
Is there anything that we should know to best support you?

Participant preference
Dietary preferences: Are you omnivore, pescatarian, vegan, vegetarian, or other? Are there anyfoods that you prefer not to eat?
Dietary allergies: Do you have any allergies to any specific foods or ingredients?
Touch: Do you have any aversions to touch? If yes, what touch? Do you have any aversions to hugs?
Fragrances: Do you have any allergies or aversions to scents?
Animals: Do you have aversions or allergies to animals? If yes, which ones?
Phobias/fears: Do you have any fears or phobias?
Aversions: Do you have any aversions to anything else (lights, sounds, language, gender, etc.)?
Concerns: Do you have any concerns about your stay with us or the experience?
Additional Information: Is there anything else that you would like to share or disclose?

Participant confirmation
I confirm that all of the information I have provided on this medical screening online form is trueand accurate to the best of my knowledge. I understand that any false ormisleading information may may have serious consequences for my health andwell-being. I acknowledge that the information provided will be used solely forthe purposes of assessing my medical condition and determining my eligibilityfor the services being applied for. By submitting this form, I agree to theterms and conditions of this application and certify that the informationprovided is complete and accurate
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Screening form

Welcome

Participant Medical History

Participant Psychological History

Psychedelics, Drugs & Alcohol History

Personal History

Participant Trauma History

Participant preference

Participant confirmation