Plant Medicine Preparation Questionnaire
Please answer the following questions.
PERSONAL INFORMATION
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred pronouns
YOUR CALL TO MEDICINE
What is calling you to work with plant medicine at this time in your life?
Have you worked with plant medicines or psychedelics before?
YES
NO
If yes, what and when?
Which medicines are you called to work with now, and why?
What are you hoping to release, understand, or transform through this experience?
Are there any specific patterns, emotions, or life themes you're currently navigating?
Do you have any spiritual practices or personal rituals you engage with regularly?
Do you feel called to a 1:1 plant medicine session or a small group session?
1:1 PLANT MEDICINE SESSION
SMALL GROUP SESSION
MENTAL + EMOTIONAL HEALTH
Do you have a history of mental health conditions (e.g., depression, anxiety, bipolar, schizophrenia)?
YES
NO
If yes, please describe.
Are you currently seeing a therapist or mental health professional?
YES
NO
Are you currently taking any psychiatric or mood-altering medications?
YES
NO
Please list names and dosages.
How do you currently manage emotional overwhelm or stress?
PHYSICAL HEALTH
Do you have any medical conditions (heart, liver, blood pressure, etc.)?
Are you currently taking any medications or supplements? Please list all.
Do you have any allergies or dietary restrictions?
Is there anything else I should know about your physical health?
SUPPORT + INTEGRATION
Do you have a supportive environment to return to after the ceremony?
Who or what helps you feel grounded when you're going through emotional or spiritual shifts?
Are you open to or interested in integration support after the experience?
AGREEMENTS + CONSENT
Please check all to confirm your agreement.
I understand that plant medicine work can bring up intense emotional and physical experiences.
I am responsible for my own wellbeing and agree to be honest in this questionnaire.
I will not withhold information about my health, medication, or mental state.
I agree to hold the space and others in it with respect and confidentiality.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: