Detailed Intake Form
Please complete this form to the best of your ability. This form is privacy-protected and HIPAA-compliant. Completing this form will take anywhere from 5 to 20 minutes and it will be sent directly to our intake team in advance of your virtual intake call, the information you provide to us here will prepare us for your call and guide your journey with us. We look forward to speaking with you. Thank you!
Basic Information
The questions in this section will gather some basic information about you.
Full Name
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Email Address
*
example@example.com
Contact Number
Are you interested in
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A Private Retreat
Group Retreat
Are you a First Responder or Military (Active or Veteran)
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No
Yes, please descibe
Are you a Canadian Citizen seeking a prescription through the Special Access. Program?
Yes
Age
*
Gender
*
Please Select
Woman
Man
Transgender Male/Trans Man
Transgender Female/Trans Woman
Non-binary
Genderqueer
Gender non-conforming
Two-spirit
Height (inches)
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Weight (pounds)
*
We ask this question for dosing purposes.
Medical History
The questions in this section will gather information about your physical health. There will be a subsequent section addressing mental health.
Do you have any allergies or intolerances?
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Please list what you are allergic or intolerant to and the type of reaction experienced. Make sure to indicate if you require the use of an epipen for your allergy.
Have you ever been diagnosed or suspect you have any of the following medical conditions:
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High blood pressure
Low blood pressure
Serious Injury
Surgery
Heart attack
Heart arrhythmia
Stroke
Heart failure
Coronary artery disease
Chest pain or angina
Epilepsy or seizure disorder
Current Pregnant or Breastfeeding
Liver or kidney failure
Cancer
Diabetes
Asthma or COPD
Traumatic Brain Injury
None of the above
Other
Further description of medical conditions, surgeries or serious injuries:
Please provide relevant details and list any other medical conditions you may have. We ask that you further describe medical conditions, particularly for conditions listed in the previous question as necessary (i.e. type of injury, surgery, etc...)
Mental Health History
This section will ask you questions about mental health conditions and psychiatric history. This information is critical to us for your well-being, please be forthcoming so that we can provide you with the best possible care and experience.
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions:
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Depression
Anxiety
Post Traumatic Stress Disorder (PTSD)
Attention Disorder (ADD or ADHD)
Obsessive Compulsive Disorder (OCD)
Schizophrenia or other psychotic condition
Bipolar disorder
Personality disorder
Substance Use Disorder or Addiction
Alcohol Use Disorder
None of the above
Other
If applicable, please describe your psychiatric conditions and any related treatments:
Please use this place to describe any psychiatric condition you have or suspect you suffer from.
Have you ever been hospitalized for a psychiatric reason? If yes, was it voluntary or involuntary? Please describe further, including how many times, for what reason(s), and when.
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Have you ever experienced suicidal thoughts or attempted self harm. If yes, please describe these thoughts or actions further here:
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Do you or any of your family members suffer from severe mental illnesses such as bipolar disorder, schizophrenia, or another serious condition? If yes, please describe here:
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Medication and Supplements
This section will collect information about medications, supplements, over-the-counter drugs, or herbal products you consume. If you do not take any medication or supplements, just write NO.
Do you take any prescription medications? If yes, please include a complete list:
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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:
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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.
Substance Use
The following questions are designed to understand more about your history and relationships to various substances.
Have you used any of the following substances in the past 3 months?
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Cocaine
Methamphetamine
Heroin or non-prescription opioids
Inhaled nitrates
GHB
Cannabis
None of the above
Iboga or Ibogaine
DMT or 5meo-DMT
LSD
MDMA
Mescaline
Ayahuasca
Ketamine
Other
Please provide any further description of substance use that you would like to share:
How much of each substance? How often? Additional commentary to substance use is helpful.
How often do you use alcohol?
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I do not drink alcohol
1 drink per month or less
1 drink per week or less
A few drinks per week
A few drinks most days
Several drinks most days
Several drinks every day
Please provide any further description of alcohol use that you would like to share:
Do you smoke or use tobacco products?
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Yes
No
Sometimes
If yes, please list the type(s) of tobacco products used, how often and in what quantity.
Please describe the type(s) of tobacco products used, how often you've used them, and in what quantity they're used.
Psychedelic Use History
This section will gather information on past use and responses to psychedelics.
Have you used psychedelics previously?
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Yes
No
If yes, please share information on your use, including the type of psychedelic, dosage and frequency. What was your experience like?
Current intention(s) with any personal psychedelic use:
Please describe the reason(s) you're considering use of psychedelics or exploring them further.
Desired outcome(s) from this experience?:
What are you hoping to receive from psychedelic use? How would you feel, think, or act different afterwards that is different than now?
Questions or topics for discussion:
Please list any questions or topics regarding any elements of this intake form or your upcoming psychedelic use that you'd like to specifically address.
Social History and Support Network
The following questions will help understand more about your current social situation and support network.
Which of the following describes your current relationship status?
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Single
Married
Single with child(ren)
Married with child(ren)
Separated or Divorced
Separated or Divorced with child(ren)
Polyamorous
In a relationship
Other
Which of the following best describes your work situation:
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Unable to work due to disability
Unemployed or underemployed
Not working by choice
Student or education program
Part time
Full time
Retired
Other
Are there any major sources of stress in your life or events that have occurred recently that have impacted your health at the moment or in recent memory?
E.g. workplace struggles? Toxic relationship? Death or loss of close persons or relationships? Changes to health or new diagnoses? Ongoing stressors, etc.
Which of the following do you consider your support network?
Therapist or Counselor
Psychedelic Integration Coach
Psychiatrist or Provider
Alternative Practitioner
Partner or Family Members
Close Friends
Psychedelic Society or Community
Church or Religious Organization
Treatment Program
Online Communities
I do not have a support network at this time
Other
Current Symptoms
The following questions are designed to create a snapshot of how you've been feeling over the last 2-4weeks. This information is very helpful to us and will influence some of the programming and supports that are offered to you.
Survey of Depression Symptoms
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Not at all
Several days
More than half of days
Almost everyday
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
Survey of Anxiety Symptoms
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Not at all
Some of the days
More than half of days
Almost Everyday
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Stressful Life Experience and Trauma Symptoms
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Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Feeling very upset when something reminded you of a stressful experience from the past?
Avoided activities or situations because they reminded you
of a stressful experience from the past?
Feeling irritable or having angry outbursts?
Feeling jumpy or easily startled?
Are there any triggers we should be aware of?
Lifestyle, Worldview and Personal Interest
Let's get to know you better.
Have there been any significant life events or experiences that led your life to change in a positive or negative way?
Are there any events in your life that you hope to avoid or suppress during your experience?
Do you have any religious or spiritual beliefs?
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Do you have any concerns or fears about the experience?
What are the areas of your life that are most important to you? (list as many or as little as you like)
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This helps provide us with a snapshot of your life. For example: Self-care, Family Members, Work, Pets, Children, Studies, Music, Online Communities, etc...
Please choose a menu option. We offer an organic menu of high-vitality foods.
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Vegan
Vegetarian
Grass-finished, locally-raised meats and seafood (additional $150)
Do you have any sensitivities or restrictions for diet, scents, sounds, etc? Please explain or list.
We aim to meet all the needs of our clients to the best of our abilities. Please note that some personal requests or preferences may not be fulfilled due to availability or operational constraints.
Submission
Almost there! These last two questions give you a chance to mention anything else you'd like to before submitting this form.
Is there anything that wasn't asked that you feel would be helpful to share? (For example: your enneagram type, Myers & Briggs or personality type, astrological sign, etc...)
Do you have any pressing questions about the program you would like answered?
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 is ONLY available to Canadians.
Please let us know how you found us.
*
Instagram
Facebook
Internet search
Friend
Other
Referral, please let us know who:
Terms and Conditions
You MUST read and agree to our Terms and Conditions (linked below and found at the bottom of each page of our website) to be eligible for any Services. Please make sure that you understand the Terms and Conditions for your safety and ours.
By providing my signature, I confirm that I have not withheld any pertinent medical information and that the information I have provided is accurate.
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