ESSENTIA Intake Form

ESSENTIA Intake Form

Thank you for taking your time to share a bit about yourself - it allows us to create a safe and intentional container for this experience. Please know that your information is received with no judgement, and held in absolute confidentiality.
Basic Information
Name*

First NameMiddle NameLast Name
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Gender*
How did you hear about Essentia?*
What is calling you to join Essentia at this time?*
Health History

The questions in this section will gather information about your mental and physical health
Have you ever been diagnosed or suspect you have any of the following medical conditions?*

Epilepsy or seizure disorderHigh blood pressureHeart attackHeart arrhythmiaStrokeHeart failureCoronary artery diseaseChest pain or anginaCurrent Pregnant or BreastfeedingLiver or kidney failureCancerDiabetesAsthma or COPDTraumatic Brain InjuryNone of the above
Description of medical condition(s)
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?*

DepressionAnxietyPost Traumatic Stress Disorder (PTSD)Attention Deficit Hyperactivity Disorder (ADHD)Substance Use Disorder or AddictionObsessive Compulsive Disorder (OCD)Schizophrenia or other psychotic conditionBipolar disorderPersonality disorderNone of the aboveOther
Description of psychiatric condition(s)
Have you ever been suicidal?
Are you taking any medications? Please list.
Please list all supplements and herbal products you are currently taking.
Do you have any allergies?
Substance Use

The following questions are designed to understand more about your history and relationships to various substances
How often do you use alcohol*

1 drink per month or less1 drink per week or lessA few drinks per weekA few drinks most daysSeveral drinks most daysSeveral drinks every dayI don't drink alcohol
Do you currently use any of the following substances?*

CocaineMethamphetamineHeroin or non-prescription opioidsInhaled nitratesGHBCannabisNone of the above
Further description of alcohol use, substance use, or anything else we should know here
Previous experience with psychedelics
Are you familiar with psychedelics?

Not at allI have some expreinceI explore and journey a lot
Which psychedelics / entheogens have you worked with before?

MDMAPsilocybinAyahuascaIboga/IbogaineLSD5-MeO-DMT / BufoDMTKetamineCannabisKamboNone of the aboveOther
Have you ever explored psychedelics in a ceremonial setting?

YESNO
Is there anything you'd like to share about your previous experience with psychedelics?
Social History and Support Network

The following questions will help understand more about your current social situation and support network
Which of the following do you consider your support network?

Partner or Family MembersClose FriendsTherapist or CounselorAlternative PractitionerChurch or Religious OrganizationOther
Are there any major sources of stress in your life at the moment or events that have occurred recently that have impacted your health?
Practicalities

Food and accommodation.
Please let us know if you have any dietary requirements, such as vegan, dairy or gluten free etc. Please also list any food allergies or sensitivities.
Are you comfortable with the magical flow of the evening as far as sleeping arrangements go (please refer to email)?

YESNO
If NO - please elaborate:
Submission

Congratulations! Almost there. Please let us know if there's anything else you'd like to share.
Is there anything else you'd like to mention you feel would be good for us to know?
Would you like to be added to our email list to receive updates about future events and offerings?*

YESNO
Should be Empty:

ESSENTIA Intake Form

Basic Information

Health History

Substance Use

Previous experience with psychedelics

Social History and Support Network

Practicalities

Submission