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
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First Name
Last Name
Cell Number
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Format: (000) 000-0000.
E-mail
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example@example.com
How did you find me/Liminal Botanica?
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Where do you live?
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What time zone are you in?
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Age:
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How would you describe your health?
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When was your last physical exam?
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Have you ever been diagnosed or suspect you have any of the following medical conditions?
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High blood pressure / hypertension
Heart arrhythmia
Heart failure
Chest pain or angina
Heart attack
Cancer
Asthma or COPD
Recent surgery or fractures
Stroke
Coronary artery disease
Epilepsy or seizure disorder
Liver or kidney problems
Diabetes
Traumatic Brain Injury
Autoimmune Disease
None of the above
Are you pregnant or nursing?
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Yes
No
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?
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Depression
Anxiety
Post Traumatic Stress Disorder (PSTD)
ADHD/ADD
Obsessive Compulsive Disorder
Schizophrenia or other Psychotic Disorder
Bipolar Disorder
Dissociative Disorder
Borderline Personality Disorder
Eating Disorder
Mania
History of suicide attempt and/or suicidal ideation
Diagnosis of psychotic disorder in an immediate family member
None of the above
If there is any family history of psychiatric conditions, please elaborate below.
Have you ever been prescribed psychiatric medications?
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Yes
No
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?
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Yes
No
Do you have any present concerns around suicide or self-harm?
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Yes
No
Do you have a history of committing any aggressive or violent behavior?
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Yes
No
Do you have any current or past substance abuse/dependence issues?
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Are you currently experiencing a crisis of any sort? If so, please share more below.
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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.)
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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?
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Do you have any prior experience with plant medicines/psychedelics?
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Yes
No
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 otherwise
extreme paranoia or anxiety, panic attacks, or other extreme negative experiences that required a significant intervention
fainted or blacked out or otherwise lost consciousness
extremely 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?
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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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