Nova Guidance Intake

Nova Guidance

amplified consciousness and the natural world
Intake
Please fill out the following form as completely as possible to help us understand your medical, mental health history and substance use history to evaluate any potential risks of participating in ceremony with us.

The information you provide here will be kept confidential and is for the creation of a safe and supportive container for working together.

While we are trained to screen for medical contraindications, we are not medical doctors. However, we have access to medical professionals for the purpose of safe and comprehensive screening should any element reside outside of our scope. As necessary, we will provide a referral for medical and pharmaceutical advice.

We're looking forward to having you join us.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact (name, relationship)
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medications and Supplements
Prescription Medications:
OTC medication, supplements, and herbal products
Medical History
Please list any known allergies (include food, supplements, medications):
Have you ever been diagnosed or suspect you may have any of the following medical conditions?
Please describe medical conditions checked above and add any not listed that are currently under medical supervision:
Do you have a family history of any cardiovascular condition?
Please list any recent surgeries or other medical procedures:
Mental Health History
Have you ever received any type of mental health diagnosis or treatment in the past? (Please include medications, support received, and pertinent dates):
Have you ever experienced any of the following?
If you answered yes to any of the above, please provide dates and any pertinent information around treatment, therapy, and current presence in your life:
Substance Use

For the purpose of this intake, psychedelic use will be explored in a separate section.
Describe your relationship with alcohol:
Do you use nicotine or tobacco products?
Do you use cannabis?
Have you used any of the following in the past 6 months?
Please include a further description of any boxes checked above:
Have you ever received inpatient or therapeutic support for substance use disorder?
Do you currently undergo any drug testing?
Psychedelic Use History

For the purpose of this question, include classical psychedelics (psilocybin, LSD, mescaline [peyote, San Pedro], DMT [N-N-DMT, 5MEO-DMT, ayauhausca]), iboga/ibogaine, 2C-molecules, MDMA, ketamine.
Please describe your history psychedelic use including recreational, psychotherapeutic, and ceremonial settings:
When was your most recent psychedelic experience and with which medicine(s)?
Support Network
Employment Status
Relationship Status
Are you currently engaged in work with any type of counselor, mentor, spiritual guide, or support group?
Are there any major sources of stress in your life at the moment or recent events impacting your wellbeing?
Current Symptoms
Depression Symptom Severity

0

1

2

3

4

5

0 is LOW, 5 is HIGH
Anxiety Symptom Severity

0

1

2

3

4

5

0 is LOW, 5 is HIGH

Trauma Symptoms

Rows	Not at all	Several days a week	More than half the days a week	Nearly every day
Unwanted memories
Feeling on edge
Avoiding thoughts, feelings, situations
Sleep disturbance

Is there anything you else you would like us to know?
Confirmation
I understand that providing inaccurate or incomplete information may impact my experience and my safety.

I hereby confirm that the information I have provided is accurate, complete, and truthful to the best of my knowledge.

I agree to inform my facilitators of any changes to any of the information provided here.

I agree to inform my facilitators of any new use of any psychoactive substances between this form and our gathering.

I agree to inform my facilitators of any changes to my physical, mental, and emotional states.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Nova Guidance

Intake

Medications and Supplements

Medical History

Mental Health History

Substance Use

Psychedelic Use History

Support Network

Current Symptoms

Confirmation