Safe Space Colorado Intake Form

Ben Johnson and Safe Space Colorado provide the following services: Entheogenic Facilitation & Integration Therapy. Ben is NOT a medical doctor or medical professional.

Do NOT drive, go right back to work or school or parenting directly after your session. Rest, gently contemplate your session, journal, nap, create art, watch TV or take a walk. Making time for good sleep is optimal the night of your session.

Entheogenic experiences facilitate access to internal resources that assist in removing blockages, reframing problems, increasing motivation & altering behavior patterns to create positive change and can simply connect pathways for an incredible participation in a non ordinary state of consciousness.

Information in this form will be used to aid in serving you as the client. Please answer honestly and know that answering yes or no to any question does not mean that you cannot receive services. Your honest answers serve as your receipt of appropriate care and service. All information is kept confidential within The Personal Information Protection and Electronic Documents Act (PIPEDA) as well as Health Insurance Portability and Accountability Act (HIPAA.)

Name

First NameLast Name

Age

Date of Birth

Date

Gender

Other

Phone Number

Format: (000) 000-0000.

May I leave messages and text you at this number?

May I use it to chat with you after visits if needed?

Email

example@example.com

May I use this email to confirm appointments or send an integration follow-up?

Address

Street Address Line 1

Street Address Line 2

CityState / Province

Postal / Zip Code

Address to be picked up at if being provided transportation. If you're not sure please contact Safe Space Colorado

Street Address Line 1

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Marital Status

Are you currently taking any medications?

If yes, then please indicate the medication name and the purpose below:

Do you have any health condition that you would like to share?

If yes, then please share them below:

Do you have any specific intentions for this journey?

Do you have any specific fears going into this journey?

Do you have any thematic healing issues or strong transitional elements in your life drawing you to this work at this time?

What is your experience with medicinal psychedelics so far? Please explain (include dates, experiences, reactions, etc):

Do you have any medical conditions or challenges that may affect you doing this work:

What regular medications and supplements do you take? Please explain the reason you take them and the effect. Please be completely honest as we are trying to avoid contraindications that may completely change your experience with the entheogenic medicines:

Please explain your relationship to any recreational drug use including but not limited to alcohol, marijuana and caffeine in the past and presently. What would your ideal relationship look like?

When was your last visit with a physician? Was anything about this visit notable? If so, briefly explain:

Have you ever had any mental health treatment such as a counselor, coach, therapist, or psychiatrist? If so, please give a brief history of your mental health treatment and the results of your treatment:

Do you have thoughts of hurting yourself or taking your own life?

Do you have thoughts of hurting someone else or taking their life?

Briefly describe your spiritual/religious beliefs or life philosophy:

What term do you use to refer to God or Universal Intelligence/Consciousness?

Issues or areas I would like to focus on during our session. Please check mark or circle those that apply (feel free to write in any notes you would like to share)

Limits on Confidentiality of Information

Clients have a right to expect that information revealed in session is not disclosed without extraordinary justification. In all other situations besides those mentioned below, signed authorization for release of information is required. The conditions that justify the release of information and by law must be reported to the appropriate agencies are the following:

1. Knowledge of child abuse or neglect

2. Knowledge of senior citizen abuse or neglect

3. A client poses a serious risk of suicide and is an imminent danger to self

4. A client poses a threat of imminent danger to another person

5. By a court issued subpoena

6. Report to law enforcement authorities, knowledge of a felony that has been or is being committed

Signature

Agreement:

I am of legal age, and in consideration of my acceptance as a participant in this session, I, for myself, my heirs, my executors, administrators, and assignees, do hereby release and discharge Ben Johnson, Safe Space, CO from all claims of damages arising from, or growing out of my participation in said activities. I agree that any claim of damages or disputes arising from my participation in sessions, should it arise, shall be settled by binding arbitration before an extra judicial arbitration and mediation service selected by the parties.

Signature

I, Ben Johnson, commit to you that I will use my expertise and knowledge to facilitate a session that has the intent to heal. It is my intention to support you in working with the issues you have mentioned and others that may arise in a positive, productive and grounded manner. I will ask for your consent for physical touch with healing intent only at the time of the session.

To be more successful in reaching my goals, client agrees to:

1. Be an active participant in the experience and see myself as a partner in the transformative nature of this process

2. Recognize that my thoughts, feelings, images, and actions have a direct effect on the quality of my life

3. Acknowledge that my well-being depends directly on how well I care for myself physically, emotionally, intellectually and spiritually

4. Accept that blaming others or myself is totally futile

5. Take responsibility for my experience of life because I create my life experience to the best of my ability in the moment with what I know right now

6. I agree to be on time for my sessions and allow advance notice should I need to cancel or reschedule a session.

Signature

Cancellation Policy

It is your right to refuse any aspect of Ben’s services and to seek the service of another provider at any time. Ben does not guarantee outcomes or results.

The scope of work is defined by what you stated was your intention during your Discovery Call and on this form. Please take an extra page to write any further on what you hope to accomplish and include any and all background information you feel to be pertinent.

Safe Space Colorado

What does connection mean to you?