Psychedelic Experience Intake Form
The questions in this section will gather some basic information about you
Name
*
First Name
Middle Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Location of Birth
Time of Birth
Gender
Please Select
Male
Female
Other
Do you identify with a particular intersectional identity, such as socioeconomic, racial, cultural or a sexuality and gender based context?
BIPOC, LGBTQIA+, etc.
Height (inches)
Weight (pounds)
Who referred you to our practice?
Are you hoping to join a group or retreat offering?
Yes
No
If yes, please indicate which:
If no, please indicate what you are seeking:
Health History
The questions in this section will gather information about your mental and physical health
Date of last physical
-
Month
-
Day
Year
Date
Date of last EKG
-
Month
-
Day
Year
Date
Are you allergic to anything?
*
Please provide a description of the allergy or intolerance as well as reaction you have below. Type N/A if you're not allergic to anything.
Have you ever been diagnosed or suspect you have any of the following medical conditions?
*
High blood pressure
Heart attack
Heart arrhythmia
Stroke
Heart failure
Coronary artery disease
Chest pain or angina
Epilepsy or seizure disorder
Current Pregnant or Breastfeeding
Liver or kidney failure
Cancer
Diabetes
Asthma or COPD
Traumatic Brain Injury
None of the above
Thyroid Condition
Insomnia
Underweight
Overweight/Obesity
Other
Description of medical condition(s)
Please use this space to FURTHER DESCRIBE medical conditions from the previous page. Information on how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc. is welcome.
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?
*
Depression
Anxiety
Post Traumatic Stress Disorder (PTSD)
ADD/ADHD
Substance Use Disorder or Addiction
Obsessive Compulsive Disorder (OCD)
Schizophrenia or other psychotic condition
Bipolar disorder
Personality disorder
Eating Disorder (Anorexia, Bulimia, Binge eating disorder)
None of the above
Other
Description of psychiatric condition(s)
Describe any PTSD or cPTSD symptoms
PTSD-like symptoms tend to be brought to awareness through psychedelic use. Could it be that you have any PTSD symptoms or experiences? Consider cultural trauma, ancestral trauma, birth trauma, & current lifespan trauma. If so, please elaborate.
Describe any significant Traumas or Core Wounds?
Description of psychiatric hospitalization(s)
Description of suicidal thoughts or attempt
Description of self injury behavior
Cutting, head banging, stabbing, swallowing or inserting object, etc.
Prescription medications
Please include a complete list of your prescription medications including the drug NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
OTC medication, supplements, and herbal products
Please include a complete list of your OTC medication, supplements, and herbal products including the NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
If there are any other files or medical records you feel are relevant please upload them here.
Browse Files
Drag and drop files here
Choose a file
Blood Work results, ECG, physical, psychiatric or therapy notes or assessments, etc.
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Substance Use
The following questions are designed to understand more about your history and relationships to various substances
How often do you use alcohol
1 drink per month or less
1 drink per week or less
A few drinks per week
A few drinks most days
Several drinks most days
Several drinks every day
Further Description of Alcohol Use
Description of tobacco use
Have you used any of the following substances in the past 3 months?
*
Cocaine
Methamphetamine
Heroin or non-prescription opioids
Inhaled nitrates
GHB
Cannabis
None of the above
Further description of substances used:
How much of each substance? How often? Any additional commentary you wish to offer.
Pyschedelic Screening
The soul lives in stories and talks in symbols, myths and things we are somehow attracted to. Each of us has their very own make up & creation history. Part of this process is to become aware what we may have received along the road of life, our personal myths and constructs, our unique family, ancestor and creation history. Every culture on earth has a creation myth that all other stories emanate from, and so do individuals. A Psychedelic Journey as well as Healing can be seen as a process of bringing into awareness, revisiting and discovering what moves us and the meaning of those stories.
Description of Past Psychedelic Use
Please describe the use and experiences with previous psychedelics.
Intention for Psychedelic Use
*
Please describe why you would like to participate in this psychedelic experience, including why you want to use any specific psychedelic and why you feel using it at this point in your life would be beneficial?
Desired Outcomes from Psychedelic Use
*
Please describe what you are hoping to receive from psychedelic use, what insights you hope to gain, What answers are you hoping to receive? What changes are you hoping to become able to implement in your life? How do you desire to feel or act differently than now?
Please take some time to describe your personal mythos & experience of childhood:
What do you hold, were told, feel and remember from your ancestors?
Do you feel you carry a particular legacy or were given a mission?
Do you have any concerns or fears about what might come up during your Psychedelic Experience?
*
FAMILY HISTORY in relation to stories & events: Every human is unique and part of living is to discover and cultivate ones gift and abilities to contribute to this world. What is your special gift or awareness? What do you feel or hope that your special gift might be?
RELATIONSHIP HISTORY, including people that really loved you or you felt love for them even if it did not evolve in a lasting relationship? Who are your closest friends and why?
Questions or topics for discussion
*
Please use this space to type any specific questions you may have about current medications or substances you're taking or about psychedelics you're interested in or plan to take.
Social History and Support Network
The following questions will help understand more about your current social situation and support network
Which of the following describes your current relationship status?
*
Single
Married
Married with Children
Separated or Divorced
Widowed
Domestic Partner
Long-term relationship
Other
Please describe your current relationship
Which of the following best describes your work situation?
*
Unable to work due to disability
Not working by choice
Unemployed or underemployed
Student or education program
Part time
Full time
Retired
Other
Have you ever had any legal problems? Please elaborate.
Are there any major sources of stress in your life at the moment or events that have occurred recently that have impacted your health?
E.g. Workplace struggles? Toxic relationships? Death of persons close to you? Change in health status? Ongoing stressors? etc.
Which of the following do you consider your support network?
*
Therapist or Counselor
Psychedelic Integration Coach
Psychiatrist or Provider
Alternative Practitioner
Partner or Family Members
Close Friends
Psychedelic Society
Church or Religious Organization
Treatment Program
Other
Please elaborate about your support network
*
How can they be involved post-ceremony?
With whom in your support network can you share your Psychedelic Experience?
Please name and list them and make a note of your relationship to them; Example: Seth (brother) Mary (Therapist) Suzanne (close work colleague): we've known each other for 15 years.
Current Symptoms
The following questions are designed to create a snapshot of how you've been feeling over the last 2-4 weeks
Survey of Depression Symptoms
*
Rows
Not at all
Several Days
More than half of days
Almost every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
Survey of Anxious Symptoms
*
Rows
Not at all
Some of the days
More than half of days
Almost every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Stressful Life Experience and Trauma Symptoms
*
Rows
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Feeling very upset when something reminded you of a stressful experience from the past?
Avoided activities or situations because they reminded you of a stressful experience from the past?
Feeling irritable or having angry outbursts?
Feeling jumpy or easily startled?
Submission
Congratulations! Almost there. These last few questions will allow us to learn more about who you are and anything else you'd like to mention.
Please describe yourself
*
How would others describe you?
*
What are your strengths?
*
What are you passionate about?
*
What are your perceived weaknesses?
*
What makes you different from most people?
Where do you feel negative feelings in your body?
Describe the feeling that triggers the body sensation. Take your time to bring up the sensation and describe as good as you can: example: “shame triggers a dull pressure like pain in my gut, followed by feeling chilly and forcing me to lower my gaze”
Current big questions or life transitions?
Describe significant Dreams you had in your life or recurrent dreams?
Is there anything else you'd like to mention?
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