ĀTMA Intake

Client Intake Form

All information is held in the strictest confidence. At no given point is information disclosed or shared.

For which service or offering are you submitting this intake form?*

Full Name*

First NameMiddle NameLast Name

How did you hear about us?

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

E-mail*

Emergency Contact*

Phone Number*

Occupation

How did you hear about us/who referred you?*

1. What is your experience with psychedelics/ plant medicine?*

2. Please list all prescription medications, drugs and/or supplements you are currently using or have used in the last 6 months. Include the name, dose, frequency and when you last consumed the medication.*

3. Do you or have you had addiction or drug dependency issues? If Yes, which substances have you had in the last 90 days? *

4. List any and all pre-existing medical conditions including but not. limited to , pregnancy, breastfeeding, heart problems, blood pressure, surgeries and/or artificial implants. *

5. Do you have any special conditions or allergies?*

6. Please tell us about any dietary restrictions or allergies. How flexible can you be during ceremony?*

7. Do you hold a specific religious belief?

8. What is your current physical fitness/activity practice? Do you have any injuries that would inhibit your movement?

9. Why are you interested in attending this retreat?

10. Please include here any additional information you'd like to share.

Are you a veteran? If so, what branch?

Client Agreement:

I understand that ĀTMA representatives do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals.

I acknowledge that psychedelic therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive psychedelic therapy as a form of therapy.

I understand that treatment given is offered as a spiritual practice through our church in order to help me to connect to the divine.

I have stated my pertinent medical conditions, and will update ĀTMA Representative of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold ĀTMA Church and facilitators from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.