Name
*
First Name
Last Name
Email
*
Purpose and Intention: What are your goals, hopes, expectations for this work? What are you seeking?
Purpose and Intention: What are your concerns or fears regarding this work, if any?
How is your sleep? Do you get a good night’s sleep? Do you have issues falling asleep or staying asleep?
Have you ever been suicidal or attempted suicide? If yes, please provide details.
Please list all prescribed medications. Indicate which are currently being used and which had been previously used (ex: Adderall, Zoloft, etc.)
Do you currently have any medical conditions? How would you describe your health?
Recreational Substances: Please list all recreational substances currently using (ex: alcohol, tobacco, etc.) Include the frequency of use (times per day/week/month and for how long of a duration you have been using: months/years)
Have you ever taken plant medicines or other psychedelics? If so, what was your experience? (Ex: Ayahuasca, cannabis, Peyote, LSD, 5-MeO-DMT, San Pedro, Salvia, MDMA, Ketamine, etc.) For each, please include a rough estimate of times used, setting in which taken (therapeutic, recreational, ceremonial, etc.), and any perceived risks/harms/difficulties and benefits/gains identified.
Self-development/resources: Please describe your current spiritual and/or self-development, self-care, and wellness practices (Ex: meditation, journaling, yoga, prayer, breath-work, etc.).
Self-development/resources: Are you part of a supportive community?
Do you have trauma or sexual trauma that would be helpful that we knew about?
Do you exercise? If so, what do you do for exercise?
Is there anything else you think we should know or that you would like to share with us before taking the next steps in this process?
Do you have any fears?
