RISE Standard Intake Form

RISE Intake Form

Please fill this out to get started on your journey. After completion, you'll be directed to a scheduling page to book your virtual call and access our medical form. We look forward to speaking with you soon. Thank you!
Basic Information

The questions in this section will gather some basic information about you.
Name
Last Name
E-mail
example@example.com
Contact Number
Age
Gender
Medical History

The questions in this section will gather a little bit of information about your physical health. Our staff may contact you about potential contraindications.
Further description of medical conditions:
Please list any other medical conditions you may have as well as further describe medical conditions, particularly for conditions listed in the previous question.
Have you ever been diagnosed or suspect you have any of the following medical conditions:

Other
Mental Health History

Please provide us with information regarding mental health conditions and psychiatric history. This information is critical to us for your well-being. Our staff may contact you about potential contraindications.
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions:

Other
If applicable, please describe your psychiatric conditions and any related treatments or in-patient stays:
Please use this place to describe any psychiatric condition you have or suspect you suffer from.
Do you or any of your family members suffer from severe mental illnesses such as bipolar disorder, schizophrenia, or another serious condition?
Have you ever experienced a heart attack or disorder, a stroke or another serious medical condition?

Yes, please describe
If you answered yes above, please describe:
Medications
Do you take any prescription medications? If yes, please include a complete list:
Please include a complete list of your prescription medications including the drug NAME, DOSE, FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is helpful. Please note, there are some medications that are contraindicated or blunt the effects of psychedelic substances, so it is important we have this information.
Do you take any OTC medication, supplements, botanical or herbal products? If yes, please include a complete list:
Please include a complete list of your OTC medication, supplements, and herbal products including the NAME, DOSE, FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is helpful. Please note, there are some medications that are contraindicated or blunt the effects of psychedelic substances, so it is important we have this information.
Psychedelic Use History

This section will gather information on past use and responses to psychedelics.
Have you used psychedelics previously?
Are you a member of the Military, a Veteran or a First Responder?

Yes, please describe
Are you a Canadian citizen who is seeking access to psychedelic substances through the Special Access Program? If yes, for what condition?
The Special Access Program (SAP) is ONLY available to Canadians who are seeking access through a prescription under the SAP.
If yes, please share information on your use, including the type of psychedelic, dosage and frequency. What was your experience like?
Questions or topics for discussion:
Please describe any questions or topics regarding elements of this intake form or psychedelic use that you'd like to specifically address.
Submission

Almost there! These last few questions help us plan your retreat.
Are you interested in an individual session or a group retreat?
What type of service are you interested in and for what dates?

Private Retreat (pls indicate your preferred dates below)
How did you find us?

Other / Referral, please let us know who:
Should be Empty:

RISE Intake Form

Basic Information

Medical History

Mental Health History

Medications

Psychedelic Use History

Submission