Guided Healing Intake Form
Basic Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health and Safety
Are you currently taking any prescription medications (especially antidepressants, mood stabilizers, or antipsychotics?
Yes
No
If yes, please list:
Have you ever been diagnosed with bipolar disorder, schizophrenia, or a psychotic disorder?
Yes
No
Have you ever experienced:
Psychiatric hospitalization
Manic episodes
Hallucinations unrelated to substance use
None of the above
Do you have any heart conditions, seizure disorders, or major medical concerns?
Yes
No
If yes, then please indicate the medication name and the purpose below:
Do you have any health condition that you would like to share?
Yes
No
Background & Readiness
Have you previously worked with altered states (meditation, breathwork, psychedelics, etc.)?
Yes
No
What is bringing you to this work right now?
What are you hoping to gain from this experience?
Acknowledgement:
I confirm the information provided is accurate to the best of my knowledge.
I understand submission does not guarantee acceptance.
I understand this work is not a substitute for medical or psychiatric care.
Signature
Continue
Continue
Should be Empty: