Personal Assessment & Guidance Intake

1
Your Full Name* This field is required.
First Name
Last Name
2
Email Address* This field is required.
example@example.com
3
Phone Number
Area Code
Phone Number
4
Current Location? (City & State)* This field is required.
5
Date of Birth* This field is required. To help us determine stage of life
Date
Month
Day
Year
6
Who are you seeking support for?Select all that apply
Myself
My partner
Myself and my partner together
A family member or loved one
Other
7
Please briefly describe your relationship situation and what you hope will improve.
Huge
Large
Normal
Small
Ok
Ok
8
What prompted you to reach out right now?* This field is required.What’s been happening that made you feel it was time to ask for guidance?
Huge
Large
Normal
Small
Ok
Ok
9
Which of the following best describes your current experience?* This field is required.Select all that apply
Feeling confused or disoriented about life or reality
Emotional intensity that feels hard to stabilize
Ongoing unhappiness or dissatisfaction I can’t resolve
Relationship patterns that keep repeating
After-effects from a significant experience (psychedelic or otherwise)
Feeling like I’m “on the edge” of something but don’t know what
Feeling pressured to make a decision and unsure who to trust
Other
10
How long has this been going on?* This field is required.(Single select)
Recent (days–weeks)
Ongoing (months)
Long-term (years)
Comes and goes
11
Right now, how stable do you feel day-to-day?* This field is required.(Single select)
Generally steady
Fluctuates but manageable
Often overwhelmed or emotionally reactive
I’m not sure / it changes a lot
12
How well are you currently able to function in your daily responsibilities (work, relationships, self-care)?* This field is required.(Single select)
Functioning normally
Functioning, but with noticeable difficulty
Struggling to function consistently
Barely functioning / overwhelmed
13
Are there any major life stressors currently affecting you?* This field is required.Select all that apply
Major relationship stress
Caregiving responsibilities
Health challenges
Financial stress
Recent loss or grief
Major life transition
None of the above
Other
14
What do you currently believe would help the most?* This field is required.Select all that apply
Clarity or understanding of what’s happening
A plan or direction to follow
Someone to talk this through with
Ongoing guidance or support
A significant experience that I believe might “reset” things
I’m not sure — I just know something isn’t working
15
When you imagine a “reset” or breakthrough experience, what do you believe that would change for you?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
16
Have psychedelic or entheogenic experiences been part of your journey so far?* This field is required.(Single select)
Yes, in the past
Yes, recently
No
Prefer not to say
17
Which types of experiences have you had?* This field is required.Select all that apply
Classic psychedelics (e.g., psilocybin, LSD)
Entactogens (e.g., MDMA)
Short-acting non-ordinary state experiences (e.g., DMT, 5-MeO)
Plant medicines in ceremonial settings
Microdosing
Not sure / Prefer not to categorize
Other
18
Are there any approaches, modalities, or experiences you’ve been reading about or feeling curious about lately?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
In your own words, what are you hoping will change as a result of reaching out?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
What kind of support are you open to right now?* This field is required.
A one-time clarity or guidance conversation
A short-term guided support container
A structured pathway or program
Self-paced resources with optional community
I’m not sure — open to recommendations
21
How willing are you to actively participate in recommendations, practices, or support pathways if they appear beneficial?* This field is required.(Single select)
Very willing — I'm ready to actively engage in the process
Willing — I understand meaningful change requires participation
Open, but unsure what I can realistically commit to right now
Interested, but hesitant
Primarily seeking understanding, information, or perspective at this time
22
Are you interested in being contacted to discuss next steps if it looks appropriate?* This field is required.(Single select)
Yes
Not right now — I mainly wanted to share where I’m at
23
If we discover additional support, resources, experiences, or ongoing guidance would be beneficial, how open are you to investing in that support?* This field is required.
Open to exploring recommendations
Open, but it depends on fit and cost
Limited resources, but open to discussing options
Unsure — I'd like to learn more first
Primarily seeking free resources and information at this time
24
Do you currently have supportive people in your life you can talk to?* This field is required.
Yes
Limited
No
25
When you think about getting help, does it feel more:* This field is required.
Calm and considered
Important but not urgent
Urgent or time-sensitive
26
Have you worked with guides, facilitators, therapists, or mentors before — and how was that experience?* This field is required.
Yes, helpful
Yes, mixed
No
Yes, harmful
27
Are you currently experiencing any of the following?* This field is required.(Select all that apply)
Severe depression affecting daily function
Active suicidal thoughts
Psychosis, hallucinations, or loss of contact with reality
None of the above
Prefer not to say
28
Anything else you feel is important for us to know?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: