ĀTMA Intake

Client Intake Form

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

After reviewing your intake form we will set up a discovery call to go over further details.

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

How did you hear about us?:

Full Name*

First NameMiddle NameLast Name

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

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

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

6. 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.*

7. Are you experiencing any physical or psychological illness that has caused or may cause hospitalization? Have you had suicidal ideations or attempts?*

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

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

10. Please share with us about any ongoing addictions or patterns you'd like to address. *

11. Please describe any impactful traumas you have experienced or are dealing with in your life. *

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

13. Please share why you would like to participate in this ceremony or retreat. What is your intention?*

14. Do you hold a specific religious belief?

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

16. 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.

If applicable, which date and time would be ideal for scheduling your session?