Mushroom Ceremony Intake form
All information is confidential and is seen only by Danielle Daniel from Microdosing Humboldt. I want your ceremonial experience to be safe and healing, so it is important that I have certain information about your history, medications, and medical conditions. Please complete this questionnaire as thoroughly as possible.
What ceremony are you interested in attending?
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Please Select
May Saturday 30th (co-ed)
July Saturday 25th (co-ed)
September Saturday TBD (co-ed)
Personalized Ceremony date TBD
Legal Name
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First Name
Last Name
Preferred name, if different than legal name
Preferred Pronoun
Date of birth
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-
Month
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Day
Year
Date
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
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Emergency Contact Phone Number
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Emergency Contact Relationship
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What are your goals and intentions with for this work?
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What are your fears or concerns about this work?
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Do you have any current or past psychological or psychiatric conditions or diagnosis? Have you had a psychotic episode? If yes to either, please give the dates and describe the circumstances.
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Do you currently see a psychiatrist, psychologist, or counselor? If so, how often?
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Do you have a personal or family history of schizophrenia?
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yes
no
Do you have a personal or family history of bipolar?
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yes
no
Have you ever been suicidal, or attempted suicide?
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yes
no
Have you ever experienced trauma? (car accident, rape, robbery, witness to violence...)
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yes
no
Have you ever been abused (mentally, physically, emotionally, or sexually?)
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yes
no
Have you had any experience with ceremonies or journeys?
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yes
no
How would you rate your overall health?
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Excellent
Good
Fair
Poor
Please share any health concerns or issues
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Please list all prescriptions and over the counter medications that you are currently taking, including their purpose and dosage.
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Do you have any allergies?
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Do you have a history of cardiovascular disorder?
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Yes
No
Do you have a history of diabetes?
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Yes
No
Do you have a history of high blood pressure?
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Yes
No
Do you have a history of seizure disorder?
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Yes
No
Do you have any breathing disorders, such as asthma?
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Yes
No
Do you have any kidney disorders?
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Yes
No
Do you have any history of any liver disorders?
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Yes
No
How often do you ingest consciousness altering substances (including alcohol and cannabis)? Please describe your experience with substances throughout your life, and those you have experienced in the past month.
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Have you had any adverse reactions to consciousness altering substances (including alcohol and cannabis)? Please describe in detail the type of substance, when, how much, the situation, and the adverse reaction.
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Is there anything else you would like me to be aware of, or any specific questions you have?
Submit
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