Intake Form
Thank you for choosing our services. Please fill out this form as completely and accurately as possible. This will help us understand your needs and provide you with the best care.
Retreat Date of interest .
5% discount reference number if any.
Name
First Name
Last Name
Date of birth
Gender
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency contact
Relationship to emergency contact
Emergency contact phone number
Please enter a valid phone number.
Marital Status
Spiritual practice/belief
Passport Expire date.
Please answer the following questions about your current health status and history.
1. What is the main reason you are seeking our services?.
2. Are you currently having any concerns re any of the following aspects of your health?
Physical/ If yes, please describe
Mental / If yes, please describe
Social/ If yes, please describe
Spiritual / If yes, please describe
If yes, please describe.
3. How long have you been experiencing this problem?
4. How severe is your problem on a scale of 1 to 10, where 1 is mild and 10 is extreme?
Physical
Mental
Social
Spiritual
5. How does your problem affect your daily life, such as your work, school, relationships, hobbies, etc.?
6. Have you ever received treatment before for any or all indicated above? If yes, please provide the name and contact information of your previous provider(s), the type and duration of treatment, and the outcome.
7. Are you currently taking any medications, supplements or otherwise ingested products natural or synthetic? If yes, please list the name, dosage, frequency, and (side) effects if any of each.
8. Do you have any medical diagnoses or allergies that we should be aware of?
9. Have you ever used psilocybin? If yes, complete below
No experience
Microdose frequently
1grams - 2.5grams occationally
5-10grams hero's dose
Date last used, highest dose and negative effects if any?
10. What do you hope to process/accomplish at this retreat?
11. Do you have a family history of any mental health condition? If yes, please indicate which relatives have been diagnosed with what conditions.
12. Have you ever been diagnosed or considered if you are dealing with any of the following?
Childhood developmental conditions eg. autism, ADHD or dyslexia.
Anxiety eg. panic or generalized anxiety
Eating eg. anorexia, bulimia
Mood eg. depression of bipolar
Trauma- and stressor-related
Psychosis eg schizophrenia or schizoaffective disorder
Personality eg narcissistic, antisocial, dependent etc
Other
None of the above
If yes to any above please provide any details you wish to share at this time.
13. Do you have any specific dietary preferences?
14. OPTIONAL TO BE COMPLETED NOW OR ON SITE. Have you ever used any psychoactive or psychedelic substance? If yes, please specify the type, amount, frequency, and duration of use.
Alcohol
Tobacco
Cannabis
Cocaine
MDMA
Ketamine
LSD
Ibogaine
Ayahuasca
Peyote
Dmt
Other
If yes, please specify the type, amount, frequency, and duration of use.
15. OPTIONAL TO BE COMPLETED NOW OR ON SITE. Have you ever self-harmed or attempted suicide? If yes, please share any details you wish.
16. OPTIONAL TO BE COMPLETED NOW OR ON SITE. Do you currently have any thoughts of harming yourself or others? If yes, please describe the frequency, intensity, and plan of these thoughts.
Please sign and date below to indicate that you have completed this form truthfully and to the best of your knowledge.
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