Client Information Safety Screening Form
Please provide some additional information about yourself in preparation for our introduction call. All answers are strictly confidential and are only reviewed by Omnia Group Ashland.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you taken the prescription drug Lithium in the past 30 days?
Yes
No
Are you currently being treated by a medical, clinical, or other healthcare provider for a medical, mental health, or behavioral health condition?
Yes
No
Have you had an allergic reaction to consuming mushrooms or other fungi?
Yes
No
Are you having thoughts of causing harm, or wanting to cause harm, to self or others?
Yes
No
Have you ever been diagnosed with active psychosis or treated for active psychosis?
Yes
No
Are you pregnant or feeding with breast milk?
Yes
No
Please list prescription medications and supplements you are currently taking, or have discontinued within the last 90 days:
Do you have a specific date or timeframe for services?
Submit
Should be Empty: