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 Name
Middle Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Other
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 disorder
High blood pressure
Heart attack
Heart arrhythmia
Stroke
Heart failure
Coronary artery disease
Chest pain or angina
Current Pregnant or Breastfeeding
Liver or kidney failure
Cancer
Diabetes
Asthma or COPD
Traumatic Brain Injury
None of the above
Description of medical condition(s)
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?
*
Depression
Anxiety
Post Traumatic Stress Disorder (PTSD)
Attention Deficit Hyperactivity Disorder (ADHD)
Substance Use Disorder or Addiction
Obsessive Compulsive Disorder (OCD)
Schizophrenia or other psychotic condition
Bipolar disorder
Personality disorder
None of the above
Other
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 less
1 drink per week or less
A few drinks per week
A few drinks most days
Several drinks most days
Several drinks every day
I don't drink alcohol
Do you currently use any of the following substances?
*
Cocaine
Methamphetamine
Heroin or non-prescription opioids
Inhaled nitrates
GHB
Cannabis
None 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 all
I have some expreince
I explore and journeyed a lot
Which psychedelics / entheogens have you worked with before?
MDMA
Psilocybin
Ayahuasca
Iboga/Ibogaine
LSD
5-MeO-DMT / Bufo
DMT
Ketamine
Cannabis
Kambo
None of the above
Other
Have you ever explored psychedelics in a ceremonial setting?
YES
NO
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 Members
Close Friends
Therapist or Counselor
Alternative Practitioner
Church or Religious Organization
Other
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)?
YES
NO
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?
*
YES
NO
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