Name
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First Name
Last Name
Email
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Date of Birth
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Place of Birth
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Phone
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What do you wish to gain, or what is your intention for pursuing a psychedelic experience?
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What is your current relationship/marital status?
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Do you have children? Do your children live with you full time? Do you live alone?
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Are you currently employed, in school or retired?
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Do you consider yourself to be spiritual/religious? Yes / No. If so describe your faith or belief.
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What do you consider to be your strengths / weaknesses? What effective coping strategies do you use?
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a.) Strengths:
b.) Weaknesses:
c.) Coping strategies:
Personality Patterns / Self Image (words you or others use to describe you)
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Please list any significant life changes or stressful events you have experienced recently (jobs, marital, children, pregnancy, abortion, relationship, legal, financial, health, housing, losses, abuse, addiction)
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Are you experienced with psychedelics?
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If "Yes”, describe the substance(s), dose(s), set(s) and setting(s), including whether for recreational, therapeutic or ceremonial use?
What influences have these had in your life?
What insights have you had during psychedelic experiences?
What types of difficulties have you worked through during your psychedelic experiences?
Have you had any challenging or problematic experience? If so please describe.
What are your attitudes or concerns about doing psychedelic experiences? Please detail any concerns.
In general, how satisfied are you with your life?
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Do you have, or have had, any of the symptoms listed below, please check the box(es) that apply.
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If you checked any of the above conditions, or if you have psychiatric conditions not listed above, please provide details and circumstances. If none, please indicate as "N/A":
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Does/did your mother/father/grandparent/siblings have any of the above listed symptoms? If “Yes” please provide details. If no, please indicate as "N/A":
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Do you currently have a psychiatrist, psychologist or counselor? If “Yes”, please indicate which type and how often you see this person. If none, please indicate as "N/A":
Have you ever been hospitalized for a psychiatric condition? If yes, please give the dates and describe the circumstances. If no, please indicate as "N/A":
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Adverse Experiences
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This section explores those experiences in your life that were overwhelming and have or may have created long lasting pain, fear, lack of trust, feelings of not being safe. Please indicate which adverse events you have experience either as a child or as an adult.
Do you regularly use Tobacco?
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Do you regularly drink Alcohol?
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Do you regularly drink Caffeine (Coffee, Energy Drinks, etc): ?
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Use of Substances
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Please inform us if you have used any of the following drugs within the past 2-years:
Have you taken any other substances not listed above?
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If “yes”, please indicate details below. If no, please note with “N/A”:
Please describe any problem use of any substances throughout your life, and especially those you have used in the past three months. If no, please indicate as "N/A":
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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. If none, please indicate with "N/A":
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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. If no, please indicate as "N/A":
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Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe. If no, please indicate as "N/A":
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Considering your age, how would you describe your overall health?
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Kindly mark any existing or previous conditions from the list provided.
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Regarding the aforementioned items, please provide information about your current or past experience with that particular condition. If you select 'Others', please indicate below. If none apply, kindly note it as "N/A":
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Do you have any other medical conditions not listed above? If “yes”, please describe and indicate (severity, age of occurrence, medical care, treatment, etc.) If none, please indicate as "N/A":
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Please list any surgeries and/or hospitalizations. If none, please indicate with "N/A":
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Please list all prescribed medication you are currently taking. If none, please indicate with "N/A":
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Have you had any adverse reactions or side effects to these medications? If “Yes”, please describe. If “No”, please indicate as “N/A”:
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Please list ALL supplements or alternative health therapies you are taking, including vitamins, minerals, herbs, homeopathics, colonics, etc. If none, please indicate as "N/A":
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Have you had any adverse reactions or side effects to supplement? If “Yes”, please describe. If “No”, please indicate as “N/A”:
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Do you have any allergies or sensitivities? Please check all that apply.
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Do you have any other allergies or sensitivities not listed above? If “yes”, please provide details below. If no, please indicate as “N/A”:
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Are you or your partner currently pregnant?
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Please list any known heart issues of immediate family members, including, but not limited to, high or low blood pressure, arrhythmia, congenital heart disease, irregular heartbeat, etc. If none, please indicate "N/A":
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To the best of your knowledge, have any immediate family members experienced mental health disorders, stroke, epilepsy, and/or seizures? If none, please indicate "N/A":
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When was your last physical exam and last Blood Test:
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Please detail any abnormal findings:
Do you have any dietary restrictions? If Yes, please provide details. If No, please indicate as "N/A":
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Exercise & Physical Activities. Please answer in the textbox.
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a) How often do you exercise? days/week
b) Are you satisfied with the level of your fitness. Yes No More or less
c) Are you satisfied with your weight? Yes No More or less
d). What physical activities do you enjoy?
Do you have difficulties with sleep? For example, difficulty falling asleep, staying asleep, sleep apnea, disrupted sleep, restless legs, nightmares, and/or insomnia? If Yes, please provide details. If No, please indicate as "N/A":
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Please share with us your use and experiences with sacred medicines. For example, Ayahuasca, San Pedro, DMT, Mushrooms, Iboga, Bufo (5MEO-DMT), LSD, MDMA, Cannabis, Ketamine, and Peyote. If none, please indicate as "N/A":
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Have you ever used any of these (or other) sacred medicines?
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Have you sat with any of these (or other) sacred medicines within the last year?
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What friend(s), loved one, counsel or other trusted person(s) do you speak with about this work?
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What practices do you have that you feel will be beneficial in helping you to integrate this experience into your life? (e.g., bodywork, journaling, meditation, time in nature, art, dance, yoga, etc.).
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Anything else we should know about you, your time with sacred medicines, or additional medical history, including use of antidepressants, or experience with mental illness, special situations, immune suppressants, health problems or chronic physical issues:
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Emergency Contact
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We do our best to assure that you have a safe and beneficial experience, yet there are risks associated with this work. Therefore, it is necessary to have the contact information for a trusted person that will be available during your session, should you need assistance getting home, or if an emergency situation arises.
First Name
Last Name
Emergency Contact Phone Number
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Relationship
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Please read the statement and sign your consent (E-signature).
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By signing this document (typing your legal name in the space below), I assume complete responsibility of any consequence or reaction following these practices and acknowledge that the organization and people involved have done a thorough effort to provide information and clarity about these practices.
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.
To the best of my knowledge, I am in good physical condition and I am not aware of any physical or psychological infirmity that would place me at risk to participate in any way.
I have researched and understand the potential risks that my participation in psychedelic treatment/event may pose risk to my physical or mental wellbeing.
I assume full responsibility for my health and wellbeing and assume any and all risks from participating in psychedelic treatment/event.
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 and will follow the recommended post event/treatment integration advice provided to me by my therapists, so that I may optimize the benefit of this experience and reduce any risks.
I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE, PERSONAL INJURY, that may be sustained by me, or any loss or damage to property owned by me, whether caused by negligence of release, or otherwise, while participating in psychedelic treatment or events, or while in, on, or upon the premises where the event/treatment is being conducted.
In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Kulandira, 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.
In signing this release, I acknowledge and represent that I have read and understand the above and sign voluntarily; I am at least eighteen (18) years of age and fully competent; I excuse this release for full, adequate and complete release of liability. I agree to all terms specified within this document.
Today's Date
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