Sacred Circle Intake Form
Ketamine Medicine Program
Date Today
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Intake by:
Your Information
Name
First Name
Last Name
Preferred Name
Community/Nation
Where are you from?
Status Card Number (if applicable)
Additional notes:
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Woman
Man
Transgender
Non-binary
Prefer not the answer
Other
Pronouns
he/him
she/her
they/them
other
Occupation
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Care Number
Emergency Contact Person
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Substance Use
Do you have concerns about alcohol or substance use that you would like to address?
yes
no
Please comment on any concerns you have about alcohol or substance use:
Alcohol Use: How many drinks do you consume per week?
None
1-2
3-5
6-10
10-20
20+
Other
Recreational Drug Use: Please select name of drug, how often used and how much used.
Rows
Yes
No
How often? (ever/per day/month/year - please indicate)
How much used per use episode (or per day/month - please indicate)
Cannabis
Cocaine
Ayahuasca
Benzodiazepine
DMT/5meoDMT
Fentanyl
GHB
Heroin
Ketamine
Kratom
LSD/Acid
Magic Mushrooms (Psilocybin)
MDA
MDMA(Molly/Ecstacy)
Morphine
Opium
PCP
Peyote
San Pedro
Other
Tobacco
Is there anything else you would like us to know about substance use - currently or in the past?
Physical Health
Current Medications:
Rows
Yes
No
Please List Names, Dosage/Times Per Day and for how long you've been taking this medication/supplement.
Are you taking any medications?
Are you taking any supplements?
Blood Pressure and Heart Rate:
Date
Blood Pressure:
Heart rate/Pulse:
Weight:
blanks
kgs; OR
blank
lbs
Medical Conditions: Do you have any of the following conditions? Please check yes or no and provide any additional information.
Rows
Yes
No
If yes, please share more here
Allergies to Food
Allergies to Medication
Allergy to Ketatine
Psychosis/Psychotic symtoms
Dementia or Delirium
Uncontrolled hypertension
Aneurysm
Pregnancy
Severe kidney disease
High risk for coronary artery disease
Uncontrolled cardiovascular disease
Severe sleep apnea
Is there anything else you would like us to know about your physical health?
Emotional
What are some of your strengths when managing obstacles in your life?
reaching out for support
talking to counsellor or therapist
cultural teachings
inner resilience
Other
Is there anything else you would like us to know about your emotional health?
Mental
Do you currently have any of the following mental health diagnoses?
Treatment resistant depression
Treatment resistant anxiety
PTSD
Substance use disorder
Are you currently taking any prescribed psychiatric medications? If yes, please provide name and dosage of medication:
Have you accessed any of the following healing to support your well-being (mental, emotional or spiritual)
Counselling
Psychiatric medicine
Traditional medicine
Traditional healing practice
Other
Is there anything else you would like us to know about your mental health?
Spiritual
Have you or your parents or other relatives in your family attended residential school?
yes
no
Have you or your parent or other relatives in your family been disconnected from their traditional territory?
yes
no
Have you had experience with altered states of consciousness? Please select any that you have had experience with:
Cultural practices (e.g., longhouse, sweat lodge, sundance, fasting)
Psychedelics medicines (e.g., LSD, Ketamine)
Plant medicines (Magic mushroom, Peyote, Ayahuasca)
Breathwork
Other
Is there anything else you would like us to know about your spiritual health?
Research
Would you be interested in participating in the research portion of this program?
yes
no
maybe, want to know more
Informed Consent
Please check yes if you agree to the following statements:
*
I understand that I am sharing personal and sensitive information with Sacred Circle.
I understand that his information will be shared with the Sacred Circle team and others works with Sacred Circle on this program, including the medical and therapeutic team, to support decisions for your safe participation in the program.
I understand that my personal information will not be shared outside of Sacred Circle program team unless there is a risk to life or life-threatening injury to myself or others.
Sacred Circle has shared information about the risks and benefits of the Sacred Circle Ketamine program, including all aspects of the holistic program (Indigenous cultural healing practices, ketamine therapy, and therapeutic counselling).
Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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