Name
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First Name
Last Name
Email
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Date 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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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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If "Yes”, describe the substance(s), dose(s), set(s) and setting(s), including whether for recreational, therapeutic or ceremonial use?
What are your attitudes or concerns about doing psychedelic experiences? Please detail any concerns.
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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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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Do you have any medical conditions? 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 all prescribed medication you are currently taking. If none, please indicate with "N/A":
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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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Green Flags
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Red Flags
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Be especially careful with clients who check one or several of the following
boxes. These issues warrant further investigation. Few of them are deal
breakers in terms of treatment, but they may indicate a poor client for
psychedelic therapy, or a less than optimal outcome from treatment. Red flags should alert you to the fact that these people have some issues around
treatment and it might be a good idea to slow things down and do more
investigation, likely in the form of a few therapy sessions to get to know them
first hand.
Today's Date
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