Have you previously received any type of mental health services? If yes, please list:
Are you currently taking any prescription medication? If yes, please list:
Have you ever been prescribed psychiatric medication? If yes, please list and provide dates:
Are you currently experiencing overwhelming sadness, grief or depression? If yes, for approximately how long?:
Are you currently experiencing anxiety, panic attacks or have any phobias? If yes, when did you begin experiencing this?:
Have you been diagnosed with a personality disorder(s)? If yes, please list:
Do you engage in recreational substance use (i.e alcohol, tobacco, marijuana, etc.)? If yes, how often and what?:
Have you ever had experience with psychedelic substances? If yes, please list:
What is your intention for using a psychedelic or plant medicine?
Are you on any medication or experiencing a health issue that may cause complications? i.e. antidepressants (SSRI’s), cardiovascular issues, etc.? Any extended treatment or past hospitalizations? Any family history of mental health challenges?
What is the main area of concern or struggle in your life right now? How long have you felt this way?
Describe your ideal life. If you could resolve your main area of struggle and live a life you LOVE, what would that loo like?
What self-improvement work (i.e. books, courses, coaching, psychedelics, retreats, meditation, somatic work, therapy, etc.), if any, have you done previously and what has been your experience with it? What has worked/not worked?
If you were guaranteed to succeed, what would you do?
If you saw someone else in your situation, what would you suggest that they do?
How will you best prepare for your experience? What is your level of commitment to creating the life you want?
What is your ideal set and setting, and what will you do to create that?
Is there anything else that you'd like to share with me?
Submit
