Initial Assessment Form

Liminal Botanica Initial Assessment Form

Hello! Thank you for your interest in working with me. Psychedelic work can be powerful, transformative, and healing...but it is not for everyone. Safety is paramount and there are some contra-indications that are necessary to assess prior to our scheduling a Consultation Call. I'm committed to creating a safe container for us and ask that you be in integrity with your responses. If there's anything broached here that you feel more comfortable discussing when we talk, please honor that and make note of it. Please know that this form is encrypted and all information shared will be kept in the strictest of confidence. If you have any questions at all, reach out to me via the contact form at LiminalBotanica.com. Many blessings, Lora 💗
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
How did you find me/Liminal Botanica?*
Where do you live? *
What time zone are you in? *
Age: *
How would you describe your health? *
When was your last physical exam? *
Have you ever been diagnosed or suspect you have any of the following medical conditions?*

High blood pressure / hypertensionHeart arrhythmiaHeart failureChest pain or anginaHeart attackCancerAsthma or COPDRecent surgery or fracturesStrokeCoronary artery diseaseEpilepsy or seizure disorderLiver or kidney problemsDiabetesTraumatic Brain InjuryAutoimmune DiseaseNone of the above
Are you pregnant or nursing?*

YesNo
Please list below any major surgeries or hospitalizations.
If you are currently on any prescription medications, please list them below including name, dosage, and frequency. (If any of them are psychiatric prescriptions please also include how long you have been taking them.)
Do you have any allergies? If yes, please detail below.
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?*

DepressionAnxietyPost Traumatic Stress Disorder (PSTD)ADHD/ADDObsessive Compulsive DisorderSchizophrenia or other Psychotic DisorderBipolar DisorderDissociative DisorderBorderline Personality DisorderEating DisorderManiaHistory of suicide attempt and/or suicidal ideationDiagnosis of psychotic disorder in an immediate family memberNone of the above
If there is any family history of psychiatric conditions, please elaborate below.
Have you ever been prescribed psychiatric medications?*

YesNo
If you have been prescribed any psychiatric medications, please list name, dose, and time period below.
Have you ever been hospitalized for a psychological or emotional reason?*

YesNo
Do you have any present concerns around suicide or self-harm?*

YesNo
Do you have a history of committing any aggressive or violent behavior?*

YesNo
Do you have any current or past substance abuse/dependence issues?*
Are you currently experiencing a crisis of any sort? If so, please share more below. *
Do you have a history of traumatic or difficult life events that have not been addressed or are not being supported therapeutically? (Please share below whatever feels comfortable for you.)*
Are you currently working with a psychotherapist? If so, what type of therapy and have you discussed your interest in a psychedelic session with your therapist?*
Do you have any prior experience with plant medicines/psychedelics?*

YesNo
If you've used plant medicines/psychedelics in the past, when was the last time and what have your experiences been? Have you had any challenging experiences? Please be as detailed as possible, including which medicines/substances were used and dosage if known.
If you've used plant medicines/psychedelics in the past, have you ever experienced any of the following:

a severe, adverse reaction physically, emotionally or otherwiseextreme paranoia or anxiety, panic attacks, or other extreme negative experiences that required a significant interventionfainted or blacked out or otherwise lost consciousnessextremely unusual or disconcerting thoughts or ideas, or extreme levels of energy (inability to sleep for days or racing thoughts, or alternatively extremely low energy) after the effects should have worn off
What are your intention/s for a plant medicine/psychedelic session at this time?*
Please use this space to share any questions or topics for discussion you have regarding this initial assessment form or psychedelic use that you'd like to talk about with me.
What did I miss? Is there anything else that would be helpful/important for me to know at this time?
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Liminal Botanica Initial Assessment Form