Clinical Intake & Informed Consent Form

Start date of process*

Date

Full name*

First NameLast Name

Current address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Contact phone number*

Please enter a valid phone number.

Email address*

example@example.com

Emergency Contact 1: Full name, relationship, and phone number*

Emergency Contact 2: Full name, relationship, and phone number*

Date, time, and place of birth*

Profession and/or level of education*

What is your current motivation for starting this process?*

Is there any family history of physical illnesses, mental health disorders, or addictions? If yes, specify the relationship and the condition.

What do you know about the circumstances of your birth? (type of delivery, complications, separation, incubator, mother’s emotional state, etc.)

Was it a natural birth, cesarean, or other method?

Were there any complications before, during, or after birth?

Do you have any allergies to medications or food?

Have you had any serious illnesses, accidents, or surgeries?

Do you have any current medical conditions? (e.g., diabetes, hypertension, epilepsy, respiratory, hepatic, infectious diseases, etc.)

Have you been hospitalized? When and for what reason?

Are you currently undergoing any medical treatment? Specify medications, dosage, and reason.

Do you take supplements, vitamins, or natural products?

Do you have any history of neurological or psychiatric disorders?

Do you currently have any relevant physical or psychological symptoms?

Are you currently under psychiatric care?*

NoYes (please provide diagnosis, provider, medications below)

If yes, please describe your psychiatric care (diagnosis, provider, medications)

Have you experienced episodes of psychosis, mania, or loss of contact with reality?*

NoYes (please describe below)

If yes, please describe (if applicable)

Addiction and Substance Use History: Please specify the substances used (including legal, illegal, and prescription medications), type, route of administration, dose, and current/past frequency.*

When did you begin using each substance? What was the progression?

Which substance do you consider to have had the greatest impact on your life?

Are you currently using? If not, since when have you been abstinent?

Have you experienced previous periods of abstinence? How long did they last?

Have you tried to quit? How many times and using what methods (clinic, group, fasting, etc.)?

Have you experienced withdrawal or detox symptoms?

Have you received medical or pharmacological treatment for addiction? What kind?

Are you currently taking any substitute medication? (e.g., methadone, buprenorphine, antidepressants, anxiolytics, antipsychotics, etc.)

Have you had any overdose, accidents, or emergencies related to substance use?

Have you been in therapy before? What type and for how long? With what outcomes?

Have you experienced depression, anxiety? Describe please

Do you have experience with non-ordinary states of consciousness? (e.g., deep psychotherapy, meditation, entheogens, etc.)

Have you previously worked with psychoactive substances? Briefly describe.

Have you ever received a diagnosis such as bipolar disorder, psychotic disorder, or personality disorder? If yes, please specify.

Do you smoke? Use alcohol or drugs? How often and since when?

How would you describe your diet? (type, quality, schedule, emotional relationship with food)

Do you exercise? What kind and how often?

How is your sleep hygiene? (hours, quality, difficulties falling or staying asleep, use of sleep aids)

How would you describe your general physical health?

How do you evaluate your personal hygiene and self-care?

Is there anything else about your physical or emotional health that feels important to share?

Religious or spiritual beliefs (if applicable)

Have you experienced suicidal thoughts in the past 6 months?*

NoYes – passive thoughtsYes – active thoughts

Have you ever engaged in self-harm (past or present)?*

NoYes (please describe below)

If yes, please describe your self-harm history (if applicable)

Have you ever attempted suicide?*

NoYes (please describe below)

If yes, please describe (when, circumstances, medical attention received)

Do you currently have thoughts, plans, or intent to harm yourself?*

NoYes (please describe below)

If yes, please describe your current thoughts or plans (if applicable)

If you are currently at risk of harming yourself or someone else, please share what support (name and phone number) you have right now and where you are located (city/country)

Are there any current legal, work, relationship, or financial consequences related to substance use? (optional)

What are you hoping this process will not be? (optional)

What motivates you to begin this psychotherapeutic process? What specific intention do you have for this cycle of inner work?*

Informed Consent, Liability Waiver, and Legal AgreementPlease read the following carefully:- I voluntarily and consciously agree to participate in a therapeutic process facilitated by Psychologist Carmen Ofelia González Bojórquez.- I understand that this process may include psychotherapy, somatic approaches, transpersonal psychotherapy, breathwork, and related methods that may evoke intense experiences.- I understand that any work related to non-ordinary experiences is limited to psychological preparation, integration, and support.- I confirm that I am participating voluntarily and may withdraw at any time.- I agree to communicate honestly about my history and state, including diagnoses, medications, substance use, and past trauma.- I understand that, in cases of acute risk, additional clinical support or postponement may be necessary.- I understand that all information will be kept confidential in accordance with Mexican law and professional ethics, and may only be shared to ensure safety or as legally required.- I consent to the professional and ethical use of somatic support and/or therapeutic touch, and may withdraw this consent at any time.- I understand that outcomes cannot be guaranteed, and I agree to participate responsibly.- I acknowledge the therapist’s right to pause or discontinue the process if deemed unsafe or inappropriate.- I accept that legal jurisdiction is in Baja California Sur, Mexico.By signing below, I confirm I have read, understood, and accept the terms outlined above.

Participant full name (print)*

First NameLast Name

Participant signature*