Medicine Intake Form
Thank you for being here. Please be honest on this form. It is important that I have reliable information so I can offer you the safest and most personalized process. You can write "n/a" for any part that does not apply to you. I will reach out to you to schedule a free consultation call to see if working together might be a good fit after you've completed this form.
Name
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First Name
Last Name
City & state where you live
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Email
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about me?
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Age
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Approx. height and weight
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Emergency contact name + phone number + relationship
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Are you pregnant or breast feeding?
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Yes
No
Gender + pronouns
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Sexual orientation
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heterosexual/straight
gay/lesbian
bi
pansexual
queer
questioning/unsure
prefer not to say
Are you in the military, a veteran or current/former first responder?
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Yes
No
Please share more about your ancestral background/roots and what that means to you.
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Please use the space below to elaborate on your general availability and work/life schedule
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Which medicine do you want to work with?
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Kambo (if applying for kambo please email me for a separate form)
Mushrooms
MDMA
Ayahuasca (dieta, prep + integration support)
Microdosing protocols
General prep + integration support for all psychedelics
Unsure
None of the above
If applying for medicine work, do you have the ability to take off work/life responsibilities for the ENTIRETY of a ceremony morning/day/night?
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Yes
No
Unsure
What is your reason for seeking out this form of healing at this time?
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Are you hoping to alleviate a specific condition or issue (physical, emotional, spiritual, etc.)? Please explain if so.
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Please detail your experience with ceremonial medicine or intentional psychedelic use. Feel free to include other types of ceremony that do not involve ingestion of a psychoactive. Include ceremony type, tradition (if any), medicine, date/time frame, dose, any lasting benefits or negative effects.
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Ex. "Ayahuasca, ~15 ceremonies, mostly in Shipibo tradition with the same community/practitioners in north and South America, over the course of five years, last one was two months ago. Psilocybin + MDMA 2x with partner in intentional context to work on relationship, experiencing strong lasting benefits with some low energy immediately after the experiences that went away."
Have you had psychedelics before in other contexts? If so, please elaborate on number of times, dosages, contexts, what the experience(s) was like for you, and any lasting benefits or negative effects.
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Check any medical condition or surgery which you have or had in the past. Check the box even if you SUSPECT you have the condition but have not received an official diagnosis.
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Heart disease of any kind (i.e., heart attacks, cardiomyopathy, valve ruptures, heart failure, arrhythmias)
Heart surgeries of any kind
Aneurysms (out-pouchings/baloonings of the blood vessel wall)
Blood clots
Diabetes type 1 or 2
Strokes
ANY conditions of your blood vessels
Tears or rupture of the esophagus
Liver disease (hepatitis, alcoholic cirrhosis, portal hypertension, fluid build up, fatty liver, etc.)
Gallbladder issues (i.e., gallstones, inflammation)
Gallbladder removed
Pancreatitis (acute or chronic)
Sinus surgeries/corrections
Gastrointestinal bleeding of any kind
Crohn's disease
Ulcerative colitis
Part of the intestine surgically removed
Lyme disease
Chronic pain
Thyroid disorder
Psoriasis
Other Autoimmune conditions (i.e., lupus, MS, celiac, etc.)
Cancer (past)
Cancer (active)
Kidney disease
Organ transplant
Chest pains
Addison's disease (condition of the adrenals)
Psychiatric diagnoses (i.e., depression, anxiety, personality disorders, PTSD, psychosis, etc.)
Addictions
Vaccination <2 weeks ago
High blood pressure (hypertension)
Low blood pressure (hypotension)
Syncope ("passing out")
Traumatic brain injury (TBI) or concussions
Military PTSD
Other medical/psychiatric conditions not listed
None of the above
Have you or a family member ever been diagnosed or struggled with with any of the following... Check all that apply
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Bipolar 1
Bipolar 2
Schizophrenia
Psychotic disorder
Borderline personality disorder
Post traumatic stress disorder
Narcissistic personality disorder
Dissociative type disorders
Other personality disorder
Delusional type disorders
Substance use disorder
Suicidality and/or self harm
None of the above
If you checked any boxes on the two lists above, please tell me more about these. Dates and timelines are particularly useful, as well as how you're currently doing.
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Please describe any other chronic/persistent health issues you experience, what you know about them, and what you've been told about what might be causing it.
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Any recent injuries/surgeries/accidents that you're recovering from? Please explain if so.
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Ever had an episode(s) of mania or psychosis? If so, please elaborate below.
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History of suicide attempts or self harm? please elaborate if so.
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List all medications/supplements you take. Include 1.) DOSE 2.) HOW OFTEN YOU TAKE IT 3.) FOR HOW LONG 4.) REASON YOU TAKE IT. See example below. This is very important. Don't leave anything out of this list, even if you think it's insignificant.
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Example: "Vitamin D- 400 IU once daily- two years- for general wellness- prescribed by primary care doctor"
Do you have allergies or food/drug sensitivities? Please elaborate. See ex. below
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Ex. "peanut allergy- anaphylaxis. happened 3 times requiring epi pen and emergency room monitoring. "
Any recent major infections or unexplained fevers?
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Do you take any of the following medications, or have you recently stopped them? If you only know your medication by brand name (i..e, "Prozac"), then look at the prescription or google it to double check with this list. Some of these may have dangerous interactions with the medicines you're wanting to work with.
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SSRI (Sertraline, Fluoxetine, Escitalopram, Citalopram, Paroxetine)
SNRI (Venlafaxine, Duloxetine, Desvenlafaxine, Levomilnacipran, Milnacipran)
MAOI (e.g., fenelzine)
DNRI (bupropion)
Tricyclyic antidepressants (amitryptaline, nortryptaline)
Anti-convulsants/Anti-seizure (e..g, keppra, lamotrigine, valproate)
Methylene blue
Antibiotics
Dopamine drugs or "antipsychotics" (clozapine, chlorpromazine, olanzapine, quetiapine, etc.)
Tramadol
Amphetamines or other stimulants
Immunosupressants (cyclosporine, tacrolimus)
Benzodiazepenes
Barbituates (phenobarbitol, primidone)
Opioids (methadone, oxycodone, hydrocodone, morphine, oxycontin)
Antiviral drugs
Antiparasite drugs
Antimalarial drugs
Anti-nausea medications (zofran, metoclopramide, meclizine, scopolamine)
None
Any drugs/medications you USED to take with regularity that you stopped over six months ago?
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Ex. "I took steroid medication on and off for 10 years for Crohn's but stopped about 3 years ago"
Are you on blood thinners? (i.e., eliquis, apixaban, warfarin, lovenox etc.)
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How often do you exercise and what do you do?
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How are you doing with the following...
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Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very satisfied
Social connections/community
Emotional health
Adaptability
Reactiveness
Physical/sexual intimacy
Spiritual/religious life
Body pain or other symptom burden
Financial situation
Self care
Energy levels
Work/employment
Life purpose
Marijuana use
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None
Yes, daily
Yes, frequently but not daily
Yes, occasionally
If you use marijuana, what are your motivations for doing so and what benefits do you gain from using it
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If you use marijuana, what undesirable effects have you noticed from using it
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What is your current relationship like with alcohol? How much do you drink, situation/environments you drink in, motivations for doing so, any desires to change the relationship, etc.
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Do you have a history of overusing alcohol? If so, please share details including how much you drank, for how many years, and if you experienced any medical complications or hospitalizations from drinking.
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What other drugs do you use recreationally, why, and how much/how often? (i.e., cigarettes, ketamine, molly/ecstasy, cocaine, heroin, crack, fentanyl, cough syrup, nitrous, DXM, etc.)
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I've included a list below of some of the most (unfortunately) common categories of traumatic experiences. Check the box of any that you feel speak to your experience. I will follow up about this in our initial conversations.
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Childhood physical abuse
Childhood sexual abuse
Childhood emotional abuse/neglect
Childhood spiritual abuse
Bullying
Adulthood sexual abuse
Adulthood physical abuse
Adulthood emotional abuse
Adulthood spiritual abuse
Spousal/relationship abuse
Narcissistic abuse
Grew up in a household with mental illness
Grew up in a household with heavy substance use or addictions
Grew up around violence
Grew up with financial insecurity
War trauma
Traumatic losses (i.e., unexpected/tragic death of friends, family members, etc.)
Traumatic birth experience
Trauma around gender
Racial/ethnic trauma
Other
none
What is your relationship like with people pleasing and boundary setting?
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What's your connection like to your inner compass/authority?
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What's your relationship like with your father and mother?
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Any concerns about ceremonies you've participated in, or issues with practitioners you worked with in the past? Please elaborate if so.
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Any bad trips/negative experiences/difficulties? Please share details and information about how you navigated them. If they required medical or psychiatric attention or hospitalization please elaborate.
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What are some grounding and wellness practices that you find supporting?
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Do you have people in your life that you can talk to about this type of work?
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Yes
No
What are three things you hope to gain in working together?
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What are three things you want to release, change, or let go of?
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Any specific fears or concerns you want me to know about?
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What would a successful outcome look like for you?
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What would a disappointing outcome look like for you?
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Although people can certainly benefit from a single psychedelic experience, many people want to explore multiple sessions/ceremonies with different dosages, or even various combinations of medicines over a longer, more personalized process. Right now I offer slightly discounted packages for these types of protocols to make it more affordable. Is this something you're interested in?
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Yes
No
Yes, but money is tight
Unsure, would need to learn more
How do you learn and process information most effectively? For example, some people do not retain information by talking, and instead prefer to read a document. Others need visual diagrams.
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Please share anything else you want me to know that will help me make working together in whatever capacity we do the best experience for you.
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