• Medicine Journey Intake

    All information provided here is considered completely confidential and will be treated as such.
  • Format: (000) 000-0000.

  • Medical History

  • Do you have any current or previous medical conditions, chronic illnesses or disabilities?
  • Do you have any allergies?
  • Do you have any history of epilepsy or seizures?
  • Do you have high or low regular blood pressure?
  • Do you have any history of irregular heart activity?
  • Have you had (or are you planning) any type of surgery or operation?
  • Have you been diagnosed with a terminal illness?
  • Have you been hospitalized for any reason within the past 5 years?
  • Have you ever experienced any of the following conditions?
  • Have you ever had an irregular EKG?
  • Have you ever experienced a traumatic brain injury or brain hemorrhage?
  • Have you ever experienced any type of liver or kidney disease?
  • Have you ever experienced any type of respiratory issues (including asthma)?
  • Do you have (or have you ever had) any tumors?
  • Have you ever experienced serotonin toxicity or serotonin syndrome?
  • Are you currently taking any medications?
  • Have you taken any of the following medications within the past three months?
  • Have you taken any of the following MAOIs within the past three months?
  • Are you currently taking any supplements?
  • Have you taken any of the following supplements within the past three months?
  • Have you taken any of the following stimulants within the past three months?

  • Psychological History

  • Do you have any history of psychiatric hospitalization within the last 5 years?
  • Have you ever been prescribed medication to manage any type of psychological state?
  • Have you ever experienced suicidal thoughts or ideation?
  • Have you ever performed an act of self-harm?
  • Have you ever beed diagnosed with any of the following?
  • Are you currently seeing a therapist or engaging in mental health support?
  • Is there anything that is preventing you from fully participating in your life?

  • Psychedelics, Drugs & Alcohol History

  • Have you ever taken psychedelic substances (including cannabis) before?
  • Are you currently active with any recreational substances (including alcohol)?
  • Are you able to go without recreational substances and/or alcohol for seven days?
  • Do you currently drink coffee, tea or caffeinated energy drinks?
  • Are you able to go without caffeine for three days?
  • Have you had or do you currently have any addictions?

  • Personal History

  • With whom do you share your most significant relationships?
  • Do you feel as if you are in a period of transition in any areas of your life?
  • Do you have any type of regular spiritual or personal development practices?
  • Have you previously participated in any form of personal development work?

  • Trauma History

  • Have you ever experienced or been witness to a traumatic event?
  • If you answered YES to the previous question, how would you describe your trauma?
  • Does the trauma still have you in a raw and vulnerable place at this moment in your life?
  • Have you had any flashbacks, nightmares or fears that have arisen due to the event?
  • Have you reached out for professional mental health support to process the trauma?
  • If you have reached out for professional mental health support, has it been supportive?
  • Are there any words, language, sounds, songs, touch, gender, or anything else that you are aware of that triggers trauma for you?

  • Preferences

  • Do you have any dietary restrictions?
  • Are you allergic to any foods?
  • Do you have any aversion to touch (including hugs)?
  • Do you have any aversions or allergies to fragrances (including sage, copal and incense)?
  • Do you have any fears or phobias that we should be aware of?
  • Do you have any aversions to anything else (e.g. lights, sounds, language, gender, etc.)?
  • Do you have any concerns about your journey session or your stay?

  • Disclaimer: Please note that I am not a doctor and am not qualified to provide health or medical related advice. Sessions are intended to support personal growth but should not be considered a substitute for psychotherapy. Working with non-ordinary states of consciousness can involve intense experiences accompanied by strong emotional and physical releases. Medicine journey work is not recommended for people with severe cardiovascular issues or hypertension, treatment-resistant psychiatric conditions, recent fractures or surgery, acute infectious diseases, epilepsy, active spiritual emergencies, and those who are pregnant. It is important to clear all intentions of medicine use with your doctor before your session.

     

    Please read and sign the following statement:

    I declare that I have read and understand the information contained above. I also declare that I have answered all questions honestly and with sufficient detail, and I have not omitted any information that I consider to be relevant.

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