Participant Health & Safety Intake Form
Complete this intake form to share your health, safety, and support needs for the participant screening and administration session planning. All fields are optional unless otherwise indicated.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical and Mental Health Screening
Medical History
Cardiovascular conditions (e.g., heart disease, arrhythmia)
History of psychosis, schizophrenia, or bipolar I disorder
Neurological disorders (e.g., seizures, epilepsy)
Pregnancy or breastfeeding
Other medical conditions
Other medical conditions details
Current Medications
Are you currently seeing a mental health provider?
Yes
No
Diagnosed mental health conditions
Any recent trauma, suicidal ideation, or hospitalization in the last 6 months?
Yes
No
If yes, please describe briefly
Please complete this section to help us assess health and safety needs.
Safety Determination and Clinical Exclusions
Safety Determination
*
Participant appears appropriate for psilocybin services at this time
Participation declined due to safety concerns
Referred to another provider or service
Reason for Safety Concern
Have you taken the prescription drug Lithium in the last 30 days?
*
Yes
No
Are you currently being treated by a medical, clinical, or other healthcare provider for a medical, mental health, or behavioral health condition?
*
Yes
No
Have you ever had an allergic reaction to consuming mushrooms or other fungi?
*
Yes
No
Are you currently taking any medications that might need to be consumed during an administration session?
*
Yes
No
Will you require assistance from an interpreter during an administration session?
*
Yes
No
Will you require assistance from a client support person for catheter, ostomy, or toileting assistance, ambulation or transfer mobility support, or medical device assistance during the administration session?
*
Yes
No
Will you require assistance from a client support person for augmentative and alternative communication (AAC) device support or assistive listening device support during the administration session?
*
Yes
No
Are you having thoughts of causing harm, or wanting to cause harm, to self or others?
*
Yes
No
Do you have a history of causing harm, or wanting to cause harm, to self or others?
*
Yes
No
Have you ever been diagnosed with active psychosis or treated for active psychosis?
*
Yes
No
If Female, are you pregnant or feeding with breast milk?
*
Yes
No
Not applicable
Do you require any assistive mobility devices?
*
Yes
No
Optional Disclosure and Planning
Would you like to share any other conditions, sensitivities, or health concerns with your facilitator?
*
Yes
No
Other conditions, sensitivities, or health concerns
Medical history or current medications that may be helpful for the administration session
Mental health history, including any traumatic experiences, that may be helpful for the administration session
Specific behaviors or internal or external stimuli that could cause discomfort during the administration session
History of substance use, including current substance use
Past experiences with psychedelics or altered states of consciousness
Information about relationships, living situation, or educational or work environment that may be affected by the administration session or require additional safety or support planning
Anything else you want us to know and consider
Participant Acknowledgment
Print Name
*
Participant Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: