INTERBLOOM Intake Form

INTERBLOOM Intake Form

Thank you so much for your interest in this course. I am really looking forward to spending time with you over the 7 weeks and learning all about you through our deep work together. Please take 10 mins to fill this form out with honesty and grace.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about this course?
Briefly describe your background or experience related to psychedelics.
Current overall physical health - on a scale of 1 - 10. 10 being fantastic, 1 being poor health.
Current overall mental health - on a scale of 1 - 10. 10 being fantastic, 1 being poor health.
How would you rate your level of personal fulfillment? Are you feeling aligned in your relationships, spirituality, and/ or career at this point in your life? Please provide some insight.
What is your occupation?
Do you take any prescription medications? Please list.
Do you exercise? What do you do, and how often?
Do you drink alcohol, or use other “drugs”, and how often?
What is your current diet like? Please include things like : plant based, meat based, fasting, snacking, emotional eating…
What type of community or relationships do you surround yourself with? Groups, family, support, therapy, inspirational…
Tell me something you love about yourself. Tell me something you dislike about yourself.
Signature to confirm the information provided is accurate.*

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