Name
*
First Name
Last Name
Email
*
Referred by
Age
*
Body Weight (lbs)
*
Occupation
What are your reasons for doing this work?
*
What are your goals, hopes, expectations?
*
What are your concerns or fears?
*
Are you experienced with medicine journeys?
*
Yes
No
If so, what types of journeys have you experienced? Has it been in a recreational or ceremonial context? Please describe in detail the type of substance taken, when, how much (if known), and the situation or purpose of taking the substance.
What influence have these journeys had on your life?
Have you had any challenging or problematic experiences? If yes, please describe in detail what you took and what happened.
During journeys, what types of difficulties have you worked through? What insights have you had?
In general, how satisfied are you with your life?
How often do you experience anxiety?
*
Regulary
Sometimes
Rarely
Never
How often do you experience depression?
*
Regulary
Sometimes
Rarely
Never
How often do you experience hopelessness?
*
Regulary
Sometimes
Rarely
Never
How often do you experience loneliness?
*
Regulary
Sometimes
Rarely
Never
How often do you experience angry outbursts?
*
Regulary
Sometimes
Rarely
Never
Do you have any current or past psychological or psychiatric conditions or diagnosis? If yes, please give the dates and describe the circumstances.
*
Do you currently see a psychiatrist, psychologist or counselor? How often?
*
Have you ever been hospitalized for a psychiatric condition? If yes, please give the dates and describe the circumstances.
*
Have you ever had a psychotic episode?
*
Yes
No
Have you ever been physically, mentally, emotionally or sexually abused?
Yes
No
If you answered yes above, which form(s)?
Have you experienced trauma (For example: Motor vehicle accidents, rape, mugging, robbery, being a witness to violence, Etc.?
*
Do you experience fear or paranoia?
*
Have you ever been suicidal? If so, when?
*
Please describe your use of any substances throughout your life and especially during the past three months.
*
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.
*
Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe.
Briefly, how much tobacco, alcohol, coffee, tea and soda do you consume?
*
Considering your age, how would you describe your overall health?
Excellent
Good
Poor
Do you currently have any medical conditions? If so, are you currently in the care of a health care professional? Please describe the conditions and current treatment.
*
Do you have a history or present condition of high or low blood pressure? If so, please explain:
*
When was your last complete physical exam?
*
MM
DD
YYYY
Could you be pregnant?
Yes
No
Do you or have you taken any anti-anxiety or antidepressant drugs?
*
Yes
No
Please list any and all medications you are currently taking as well as the dose and for how long you have been taking them.
*
Are you more or less sensitive to medications than most people? (i.e. Have you had to take more or less of a medication’s recommended dose to experience the desired effects?) If so, please describe:
*
Have you had any adverse reactions to medications or supplements? Do you experience side effects from medications or supplements? If so, please describe:
*
Do you take Guarana, 5htp, St John's Wort, GABA, or Licorice? Please name any below and how long you've taken them.
*
Have you had any adverse reactions to medications or supplements? If so, please describe:
How would you describe your satisfaction in your relationships?
How would you describe your spiritual beliefs and practices?
How satisfied are you with your sense of community?
I have incredible supportive community
I have great connections most of the time
I sometimes feel connected to community
I rarely connect with others
I am pretty isolated
What are your self-care practices? How do you nurture yourself?
How do you cope with stress and challenges in your life?
*
Have you ever been involved in a lawsuit? If yes, please describe:
*
Describe your sexual orientation, expression and pronouns.
Are you satisfied with your current sexual experiences?
Yes, always
Often
Sometimes
No
Is there any sexual trauma that has been or needs to be healed?
This work may lead to profound shifts in your life. It is important to put resources in place to support you before and after sessions, so you can better integrate the experience and get the most benefit. Who (friend, loved one, counselor or other trusted persons) can you speak with openly about this work? How supportive are they about your doing this work?
What practices do you think might help you to integrate this experience into your life? (i.e., speaking with trusted persons, art, bodywork, journaling, time in nature, etc.)
We recommend counseling to support your integration. If you are not already a regular client, who will support your integration?
What else do you want to share with us about yourself, or what questions would you like to discuss?
For zoom clients or sessions in your hometown only:While we have never needed this, please provide contact information for a trusted person should you need assistance during your journey. It is best if this contact be someone who could get to your residence in 15 minutes or less if the need arose.
We do our best to assure a safe and beneficial experience, yet there are risks associated with this and any psychospiritual or therapeutic work. By typing your name and the date below, you acknowledge that you are solely responsible for your actions, including the ingestion of any substances that you may take.
Date
MM
DD
YYYY
