ASJ INTAKE FORM

INTAKE QUESTIONNAIRE

REQUIRED FOR ALL PARTICIPANTS
The first step in your process is to determine if this work is right for you, right now. Please complete and return this Questionnaire before scheduling a Pre-Journey Intention Call. In that call we will have a chance to go through this material together more deeply.

Please answer each question with honesty and transparency so that you can be supported in the way that you need to be supported through this process. Be transparent about any medical conditions, medications, supplements, life experiences or habits that will undoubtedly impact and influence your experience.

The goal is that you have the most amazing and safest experience possible and are cared for well in this community. Please note that this is a confidential record.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender Identification
How did you hear about Awakened Soul Journeys?
PAST PSYCHEDELIC EXPERIENCE
1. What has been your experience with psychedelic medicines (psilocybin, LSD, DMT, Mescaline, San Pedro, Ayahuasca etc.)? What medicines have you taken and when?
2. If so, describe the substance(s), dose(s), set(s) and setting(s). Was it in a Recreational, Therapeutic or a Ceremonial context? Was it in community or alone?
3. Please describe, in detail, the types of substance taken, when, how much (if known), and the situation or purpose of taking the substance.
4. What influence have these experiences had on your life, if any?
5. Have you had any challenging or problematic experiences with psychedelics?
6. IF you have had any problematic experiences, please describe, in detail, the type of substance taken, when, how much (if known), and the situation.
7. What insights have you had during psychedelic experiences?
8. What types of difficulties have you worked through during psychedelic experiences?
9. What are your concerns/attitudes about engaging in psychedelic experiences? Please describe any concerns.
10. What do you wish to gain from this experience? What are your intentions in pursuing this work?
11. What has you choosing to be a part of a community in doing this work instead of solo?
12. What concerns or inquiries do you have about being community?
13. What are past experiences of being in community that have been healing, or experiences that have resulted in hurt or confusion?
14. What is your intention in using community for your healing?

SUBSTANCE USE HISTORY
22. How often do you use alcohol, drugs, or any consciousness-altering substances? Please describe your use of any substances throughout your life, and those you have used in the past three months.
23. Have you had any adverse reactions to alcohol, drugs, or any consciousness-altering substances? Please describe in detail the type of substance taken, when, how much (if known), the situation or purpose of taking the substance, and the adverse reaction.
24. Are you sensitive or tolerant to any substances? Have you had to take more or less of a substance than usual to experience an effect? If so, please describe.
25. Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe.

DETAILED MEDICAL HISTORY - OVERALL HEALTH
26. Considering your age, how would you describe your overall health?

1

2

3

4

1 is Worst, 4 is Best
27. In general, how satisfied are you with your life?
28. Do you have any medical conditions? If so, are you currently in the care of a health-care professional? Please describe the conditions and current treatment.
30. Do you have a history or present condition of high or low blood pressure?
31. Do you have any history of iron deficiency anemia? If so, when and where/are you being treated?
32. When was you most recent complete Physical Exam: Last Blood Test: Month & Year
33. Were there any abnormal findings?
34. For the following, please describe event and list date of occurrence:
A. Surgeries
B. Major Accidents
C. Hospitalizations

EMERGENCY CONTACT
In the event of an emergency who should we contact? Please make them aware that you are planning to undergo this journey.
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please read and sign:

I understand that accurate reporting of the above information is necessary to help ensure that I have a safe and beneficial experience. I realize that failure to provide accurate information may compromise my experience. I have answered this questionnaire truthfully to the best of my ability.

I am responsible for my health and I understand that my participation in this event may pose some risks. To the best of my knowledge, I am in good physical condition and I am not aware of any physical or psychological infirmity, which would place me at risk to participate in any way.

Private Communication – not for reproduction or copy, not medical advice, sole property of Sheridan Counseling & Coaching

In the event of a medical emergency, I agree to seek emergency medical care and give permission to initiate contact with emergency medical providers. I will utilize appropriate support so that I may optimize the benefit of this experience and reduce any risks.

In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the Guide(s), Sitter(s) and participants from any and all liability, claims, demands, or course of action whatsoever arising out of, or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted.

I agree to indemnify and hold harmless those with whom I engage this work.

I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise.

In signing this release, I acknowledge and represent that I have read, understood and signed the form voluntarily; I am an adult, of at least eighteen years of age or older, and fully competent; and I execute this Release for full, adequate and complete considerations fully intending to be bound by same.

This waiver applies to all present and future work with this Guide, Leader/Organization.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

Rows	1	2	3
Anxiety
Hopeless Outlook
Poor Memory
Depression
Lonely
Dislike Criticism
Bad Temper
Easily Stressed
Nervousness

Rows	Yes	No	Past
Allergies
Anemia
Anxiety
Asthma
Auto-Immune Disease
Bipolar Disorder
Cancer
Depression
Diabetes
Heart Attack
Heart Disease
Headaches/migraines
High Blood Pressure
Liver Disease
Osteoporosis
Psychosis
Schizophrenia
Stroke
Thyroid Disease

Rows	Yes	No	Past
Antacids
Antibiotics
Antidepressants
Asthma Meds
Anti-anxiety meds
Blood Pressure meds
HIV meds
Laxatives
MAOI's
Pain relievers
Sedatives
Sleeping Pills
Stimulants
Steroids

Rows	Yes	No	Past
B Vitamins
5-HTP
Melatonin
SAM-e
GABA
L-Tyrosine
Guarana
Licorice
St. John's Wort

Rows	Yes	No	Past
Tobacco
Caffeine
Alcohol
Soda

INTAKE QUESTIONNAIRE

PAST PSYCHEDELIC EXPERIENCE

MENTAL HEALTH HISTORY

SUBSTANCE USE HISTORY

DETAILED MEDICAL HISTORY - OVERALL HEALTH

34. For the following, please describe event and list date of occurrence:

PERSONAL AND FAMILY HISTORY

ALLERGIES/SENSITIVITIES

DIET AND DIGESTION

SLEEP

PERSONAL HABITS

EMERGENCY CONTACT