REMEMBRANCE Intake Form

REMEMBRANCE Intake Form

The questions in this section will gather some basic information about you.
Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age
Gender
Health History

The questions in this section will gather information about your mental and physical health
Are you allergic to anything?
High blood pressureHeart attackHeart arrhythmiaStrokeHeart failureCoronary artery diseaseChest pain or anginaEpilepsy or seizure disorderCurrent Pregnant or BreastfeedingLiver or kidney failureCancerDiabetesAsthma or COPDTraumatic Brain InjuryNone of the above
Description of medical condition(s)
DepressionAnxietyPost Traumatic Stress Disorder (PTSD)Attention Deficit Hyperactivity Disorder (ADHD)Substance Use Disorder or AddictionObsessive Compulsive Disorder (OCD)Schizophrenia or other psychotic conditionBipolar disorderPersonality disorderNone of the aboveOther
Description of psychiatric condition(s)
Prescription medications and/or OTC meds
Substance Use

The following questions are designed to understand more about your history and relationships to various substances
yesoccasionallyno
Describe any narcotics or drug use within the last 3 months :
Description of Past Psychedelic Use
Intention for your Journey (optional)
Questions or topics for discussion (optional)
Are there any major sources of stress in your life at the moment or events that have occurred recently that have impacted your health?
Current Symptoms

The following questions are designed to create a snapshot of how you have been feeling over the last 2-4 weeks

Survey of Depression Symptoms-complete if you are dealing with depression

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-complete if you are dealing with anxiety

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?

Would you like a pre-workshop intake call? (optional)
INFORMEND CONSENT & RELEASE OF LIABILITY I, ____________________________________________________________________________, hereby declare and agree that:

1. I am choosing to participate in a workshop conducted by Remembrance Gatherings led by Jason Mitchell and Gina Messick that involves prayers and meditations involving sacred sacraments in the form of psychedilic mushrooms taken from the earth.

2. I understand that some of the processes in the workshop may at times be physically, emotionally or mentally stressful or challenging; and I assume full responsibility for my own health and well-being.

3. All medical or psychiatric conditions I have, which could affect my ability to participate in the workshop or potentially cause me to risk harming myself or other participants are clearly stated in the Medical Information section of this form. All anti-depressants or mood altering medications I am taking are clearly stated in the Medical Information section of this form.

4. I understand that the workshop is not being offered as a treatment or therapy for any physical or psychological condition and that if medical or psychotherapeutic treatment is desired or required by me, I will seek appropriate professional help.

5. I will release and hold harmless Jason Mitchell and Gina Messick, as the leadership of of Remembrance Gatherings as well as Remembrance Gatherings, a 508c3 non profit religious organization and any facilities utilized for space from any loss, liability, injury, or damage, which may arise, in connection with my participation in the workshop.

6. I agree to not engage in any form of litigation or legal action against Jason Mitchell or Gina Messick, the leadership team of Remembrance Gatherings and to resolve any disputes or disagreements that many arise by direct or mediated negotiation.
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REMEMBRANCE Intake Form

Health History

Substance Use

Current Symptoms