Microdose Coaching Intake Form
Thank you for your interest in my Microdose Coaching Program! The following questions will help me gather some basic information about you to see if this is a good fit!
Name
*
First Name
Middle Name
Last Name
E-mail
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
Please Select
Male
Female
Other
Height (inches)
Weight (pounds)
Health History
The questions in this section will gather information about your mental and physical health
You you allergic to anything?
*
Have you ever been diagnosed or suspect you have any of the following medical conditions?
*
High blood pressure
Heart attack
Heart arrhythmia
Stroke
Heart failure
Coronary artery disease
Chest pain or angina
Epilepsy or seizure disorder
Current Pregnant or Breastfeeding
Liver or kidney failure
Cancer
Diabetes
Asthma or COPD
Traumatic Brain Injury
None of the above
Do you have any other medical conditions?
*
Yes
No
Description of medical condition(s) (if applicable)
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
Have you ever been hospitalized for a psychiatric reason?
*
Yes
No
Description of psychiatric condition(s) (if applicable)
Description of psychiatric hospitalization(s) (if applicable)
Description of suicidal thoughts or attempt
Prescription medications
OTC medication, supplements, and herbal products
If there are any other files or medical records you feel are relevant please upload them here.
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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
Further Description of Alcohol Use
Further description of tobacco use
Have you used any of the following substances in the past 3 months?
*
Cocaine
Methamphetamine
Heroin or non-prescription opioids
Inhaled nitrates
GHB
Cannabis
None of the above
Further description of substances used:
Description of Past Psychedelic Use
Intention for Psychedelic Use
*
Desired Outcomes from Psychedelic Use
*
Questions or topics for discussion
*
Social History and Support Network
The following questions will help understand more about your current social situation and support network
Which of the following describes your current relationship status?
*
Single
Married
Married with Children
Separated or Divorced
Widowed
Other
Which of the following best describes your work situation?
*
Unable to work due to disability
Not working by choice
Unemployed or underemployed
Student or education program
Part time
Full time
Retired
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?
Which of the following do you consider your support network?
*
Therapist or Counselor
Psychedelic Integration Coach
Psychiatrist or Provider
Alternative Practitioner
Partner or Family Members
Close Friends
Psychedelic Society
Church or Religious Organization
Treatment Program
Other
Current Symptoms
The following questions are designed to create a snapshot of how you've been feeling over the last 2-4 weeks
Survey of Depression Symptoms
*
Rows
Not at all
Several Days
More than half of days
Almost every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
Survey of Anxious Symptoms
*
Rows
Not at all
Some of the days
More than half of days
Almost every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Stressful Life Experience and Trauma Symptoms
*
Rows
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Feeling very upset when something reminded you of a stressful experience from the past?
Avoided activities or situations because they reminded you of a stressful experience from the past?
Feeling irritable or having angry outbursts?
Feeling jumpy or easily startled?
Submission
Congratulations! Almost there. These last few questions will ensure you understand more about the terms and conditions of submitting this intake form and give you a chance to mention anything else you'd like to.
Is there anything else you'd like to mention?
Birth Details (for Human Design Reading)
I use this information to do a Human Design reading for you.
I use this information to do a Human Design reading for you.
Date of Birth
*
-
Day
-
Month
Year
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Exact Time of Birth
*
Hour Minutes
AM
PM
AM/PM Option
City of Birth
*
State / Province of Birth
*
Country of Birth
*
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