Intake Form

Background

Age*

Body Weight (lbs)*

Occupation*

Level of Education*

Purpose

What are your goals, hopes, expectations for this work? What are you seeking?*

What are your concerns or fears regarding this work?*

Medicine Journey Experience

Have you ever taken plant medicines or other psychedelics?*

If so, what was your experience? Has it been in a recreational or ceremonial context?*

What influence have these experiences had on your life?*

During these experiences, what types of difficulties have you worked through? What insights have you had?*

Have you had any challenging or problematic experiences?*

If yes, please describe in detail what you took and what happened:*

Substance Use History

Have you used alcohol, drugs, or consciousness-altering substances?*

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?*

Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe.*

How much tobacco, alcohol, coffee, tea and soda do you consume?

Cigarettes (per week)*

Alcohol (per week)*

Cannabis (times per week)*

Cups of coffee (per day)*

Cups of tea (per day)*

Soda (ounces per day)*

Have you had any adverse reactions to substances? If yes, please describe.*

Are you sensitive or tolerant to any substances? If yes, please describe.*

Mental Health

In general, how satisfied are you with your life?*

Mostly Disappointed,	Somewhat Disappointed	Satisfied	Very Satisfied

To what extent do you have these symptoms?*

	Never	Sometimes	Often	Constant
Anxiety
Depression
Bad Temper
Hopeless Outlook
Lonely
Easily Stressed
Poor Memory
Angry Outbursts
Nervousness
Lost

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 circumstances.*

Have you ever been suicidal or attempted suicide? If yes, please provide details.*

Have you ever been abused? Was the abuse physical, mental, emotional, sexual?*

Have you experienced trauma?*

Trauma is the response to a deeply distressing or disturbing event that overwhelms an individual’s ability to cope, causes feelings of helplessness, diminishes their sense of self and their ability to feel the full range of emotions and experiences. This also includes exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): Direct exposure, Witnessing the trauma, Learning that a relative or close friend was exposed to a trauma, Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

Please describe your experience of trauma?*

Do you have any issues around trust? Please describe.*

Do you experience anxiety, fear or paranoia? If so, how often. Please describe.*

Medical History (1/3)

How would you describe your health?*

Poor	Fair	Good	Excellent

Do you currently have any medical conditions?*

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.*

Do you have any history of iron deficiency anemia? If so, please explain.*

Could you be pregnant?*

Rough Date of Last Complete Physical Exam*

MM slash DD slash YYYY

(Choose the first of the month if you don’t remember the exact day)

Rough Date of Last Bloodwork*

MM slash DD slash YYYY

(Choose the first of the month if you don’t remember the exact day)

Any abnormal findings from the last physical or bloodwork?*

Medical History (2/3)

For the following please describe event and list date of occurrence

NOTE: if the answer is ‘no’ just write ‘none’

Surgery*

Date

MM slash DD slash YYYY

Major Accidents*

Date

MM slash DD slash YYYY

Hospitalization*

Date

MM slash DD slash YYYY

Personal and Family History

Please select whichever applies and leave blank ones that don’t apply.

Allergies

Anemia

Anxiety

Asthma

Autoimmune Disease

Bipolar Disorder

Cancer

Depression

Diabetes

Heart Attack

Heart Disease

High Blood Pressure

Liver Disease

Osteoporosis

Psychosis

Schizophrenia

Stroke

Thyroid Disease

Cardiovascular Disease

Irregular Heart-rate

Seizure Disorder

Are you taking/have you taken any of the following medications?

	Currently	Never	In the Past
Antacids
Antibiotics
Antidepressants
Anti-anxiety Meds
Asthma Meds
Blood Pressure Meds
HIV Meds
Laxatives
Pain Relievers
Sedatives
Sleeping Pills
Stimulants
Steroids
Hormone Replacement

Medical History (3/3)

What medications are you currently taking? (It is essential that you list ALL Rx meds)

Medication #1

Dosage

For What?

Since When?

Medication #2

Dosage

For What?

Since When?

Medication #3

Dosage

For What?

Since When?

Medication #4

Dosage

For What?

Since When?

Medication #5

Dosage

For What?

Since When?

Are you more or less sensitive to medications than most people? If so, please describe:*

Do you take (or have you taken) any of the following supplements regularly?

B-Vitamins

Current

Past

L-Tyrosine

Current

Past

5-HTP

Current

Past

L-Tryptophan

Current

Past

SAM-e

Current

Past

Guarana

Current

Past

St. John's Wart

Current

Past

Licorice

Current

Past

GABA

Current

Past

What supplements are you taking? Be sure to include any vitamins, minerals, herbs, homeopathic, and other health aids.

Supplement #1

Dosage

For What?

Since When?

Supplement #2

Dosage

For What?

Since When?

Supplement #3

Dosage

For What?

Since When?

Allergies. Check all that apply.

Antibiotics

Alcohol

Aspirin

Citrus

Codeine or morphine

Dairy

Dust

Fumes

Grass

Molds

Penicillin

Pets

Pollen

Smoke

Trees

Weeds

Wheat

Scents

Are you allergic to any other allergies not mentioned on the list?*

Family

Relationship Status*

Are you currently in romantic relationship(s)?*

For how long have you been in relationship?*

On a scale of 1-10, how would you rate your satisfaction with your current romantic relationship(s)?

Who are the most important people in your life?*

Children, if any? (please list ages)*

Are both of your parents still living?*

Do you currently have a relationship with your parents? With mom? With dad?*

What age were you when your parent(s) passed?*

Did your parents go through a separation? If so, what age where you when they separated? What was the custody arrangement?*

Do you have siblings? (please list ages)*

Is there anything else about your family of origin to know about? Neglect, violence, deaths, alcohol, religious oppression, absent parent, depressed parent, mentally unstable parent?*

Diet

Any dietary restrictions or regimens? If yes, please describe.*

Do you have an eating disorder? If so, please describe.*

How much water do you drink daily?*

Do you find food …*

Do you eat grapefruit regularly?*

Exercise

Do you exercise?*

What do you do for exercise?*

Are you satisfied with your level of fitness?*

Are you able to carry a bag of groceries up stairs without needing to take a break?*

Sleep

# hrs/night*

Wake up refreshed?*

Issues falling asleep?*

Issues staying asleep?*

Personal

Do you have a spiritual practice? Please describe.*

Who do you rely on for emotional support?*

Do you have a social network?*

Are you satisfied with your social relationships?*

What groups or communities are you a part of?*

Do you have hobbies? What do you enjoy in your free time?*

What are your self-care practices? How do you nurture yourself?*

Work Life

What are your coping mechanisms? How do you deal with stress and life challenges?*

Have you been involved in any legal disputes or lawsuits?*

Please describe the nature of the legal dispute or lawsuit.*

Sexuality

Describe your sexual development, orientation, and expression?*

Are you satisfied with your sexual experiences?*

Is there any sexual trauma that has occurred or needs to be healed?*

Integration

This work may lead to profound shifts in your life. It is ideal to have resources in place ahead of time to support you before, during and after sessions. Having support will help you integrate the experience and help you get the most out of the work.

What friend, loved one, counselor or other trusted person(s) do you speak with about this work? What do they think about you pursuing this work?*

Do you have a network of support to assist you in integrating this work? Please describe (be specific)*

What practices have you found helpful in integrating powerful life experiences? (e.g. art, bodywork, journaling, time in nature, speaking with a friend, etc.)*

Counseling is recommended to support your integration. If you are not already a regular client, who will support your integration, and how will you utilize them?*

What else do you want to share with us about yourself, or what questions do you want to discuss?

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Intake Form

Please complete this form as thoroughly as possible.

Background

Purpose

Medicine Journey Experience

Substance Use History

How much tobacco, alcohol, coffee, tea and soda do you consume?

Mental Health

Medical History (1/3)

Medical History (2/3)

For the following please describe event and list date of occurrence

Personal and Family History

Medical History (3/3)

What medications are you currently taking? (It is essential that you list ALL Rx meds)

Do you take (or have you taken) any of the following supplements regularly?

What supplements are you taking? Be sure to include any vitamins, minerals, herbs, homeopathic, and other health aids.

Family

Diet

Exercise

Sleep

Personal

Work Life

Sexuality

Integration

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