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Mi Soldado: Transforming Trauma Into Strength
This intake form is confidential and voluntary. Please answer honestly to help us support your healing process.
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Full Name ✳️
*
First Name
Last Name
Email ✳️
*
example@example.com
Mobile phone (+country code) ✳️
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Please enter a valid phone number.
Social Media (Instagram or other)
Birth Date ✳️
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-
Month
-
Day
Year
Date
Emergency Contact Phone ✳️
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Please enter a valid phone number.
Unit/Service Background
What brings you to this program at this moment? ✳️
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What is your main intention for joining this healing process? ✳️
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List up to three symptoms that are difficult for you right now — table: Symptom | Duration | Intensity 1-5
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Symptom
Duration (Months, years)
Intensity (1-5)
1
2
3
How have these difficulties affected your life? (Relationships / Work or studies / Legal or military / Physical health / Sleep)
Are you currently under medical care or do you have an active condition? (Yes/No) → describe
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Yes
No
Describe your medical condition or active health issues.
List any medications you take (name | dose | reason)
Have you had any injury, concussion, or chronic pain? (Yes/No) → describe
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Yes
No
Describe your injuries, concussion, or chronic pain.
Cardiovascular history
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Please Select
None
Arrhythmia
Heart attack
Cardiac surgery
Other
Describe your cardiovascular history if 'Other'
Sleep — How many hours per night? ✳️
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Is it easy for you to fall asleep? (Yes/No/Sometimes)
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Yes
No
Sometimes
Rate your daytime energy 1–5 ✳️
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Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Movement or exercise frequency
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Please Select
Daily
Often
Sometimes
Rarely
Never
Substance use days per month
Caffeine
Alcohol
Cannabis
Cigarettes
Psychedelics (micro/full)
Other
Substance
0
1-5
6-10
11-15
16-20
More than 20
0
1-5
6-10
11-15
16-20
More than 20
0
1-5
6-10
11-15
16-20
More than 20
0
1-5
6-10
11-15
16-20
More than 20
0
1-5
6-10
11-15
16-20
More than 20
0
1-5
6-10
11-15
16-20
More than 20
Nutrition
*
Please Select
Balanced
Needs improvement
Irregular
Unhealthy
Food allergies or restrictions
What does your body need most right now?
Have you been diagnosed with PTSD, depression, anxiety, or other?
PTSD
Depression
Anxiety
Other
Are you taking or have you taken psychiatric medication? (Yes/No) → details
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Yes
No
Describe your psychiatric medication use.
Any hospitalization or psychosis? (Yes/No) → details
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Yes
No
Describe your hospitalization or psychosis.
Family history
Please Select
Schizophrenia
Bipolar
Depression
Substance use
None
Have you had thoughts of suicide or self-harm? (Never/Past/Recently) ✳️
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Never
Past
Recently
If 'Recently', please confirm phone and best time to reach.
What are your main current challenges? (Sleep / Concentration / Motivation / Flashbacks / Anger / etc.)
What helps you calm down when you are triggered?
Describe any significant trauma (before/during/after service).
Who are the people closest to you right now?
Are your parents alive? How is your relationship with them? (Both alive close / Both alive complicated / One alive / None / Prefer not to say)
Please Select
Both alive close
Both alive complicated
One alive
None
Prefer not to say
Can you talk about your emotions with someone? (Yes / Sometimes / No)
Yes
Sometimes
No
What brings you calm or joy?
Difficult feelings lately (select up to 3)
Anger
Fear
Loneliness
Sadness
Guilt
Hopelessness
Grief
Have you lost someone close (during or after service)? (Yes/No) → describe
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Yes
No
Describe your loss.
Have you felt you needed to “shut down” emotionally to survive? (Yes/No) → describe
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Yes
No
Describe your emotional shutdown.
What gives your life meaning today?
Do you believe in something greater than yourself? (Yes / Unsure / No) → describe
Please Select
Yes
Unsure
No
What does faith or hope mean to you?
Previous psychedelic experience (No / Yes → substance | context | effect)
No
Yes
Describe your psychedelic experience.
If you could imagine full healing, what would life feel like?
Anything else we should know?
Confidentiality statement and consent paragraph.
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I confirm this information is true and consent to share it with the clinical/research team. ✳️
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I agree
Typed signature ✳️
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Date (auto today) ✳️
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-
Month
-
Day
Year
Date
Submit
Submit
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