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Condensed Medical Intake

This is a short version of our typical intake form. It does not include the usual comprehensive psychological profile we collect. If you’re interested in completing the full intake form, you can find it here.

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Basic Information

Full Name*

First Last

Age*

Mobile Number*

Email*

Enter Email Confirm Email

Emergency Contact Name*

Emergency Contact Phone Number*

Are you currently pregnant?*

Yes

No

Not applicable

Physical Health

Your safety and well-being are our highest priorities. Please answer all questions honestly and completely. Answering in the affirmative does not mean you will be excluded — our team will follow up if further clarification is needed.

Height (feet and inches)*

Weight (pounds)*

Are you currently taking any medications?*

Yes

No

Please list all current medications, including dosage and frequency.*

Have you taken any medications in the last 6 months that you are currently NOT taking?*

Yes

No

Please list those medications, including dosage and how long you were taking them.*

Are you currently taking any vitamins or supplements?*

Yes

No

Please list all vitamins and supplements you are currently taking.*

Are you allergic to any medications?*

Yes

No

Please list the medications you are allergic to.*

Do you have any severe or potentially life-threatening allergies that would require the use of an EpiPen?*

Yes

No

Please list the allergies that require an EpiPen.*

Cardiac / Cardiovascular Health — please check any that apply:

High Blood Pressure

Irregular Heartbeat

Heart Attack

Stroke

Aneurysm

Circulatory Problems

Other

None of the above

Please provide details about any cardiac/cardiovascular conditions checked above.

Other Physical Health Conditions — please check any that apply:

Epilepsy or Seizures

Diabetes

Thyroid Conditions

Fainting

Cancer

Infectious Disease

Physical Disability

Other

None of the above

Please provide details about any physical health conditions checked above.

Have you suffered any recent injuries or disabilities?*

Yes

No

Please provide details about your recent injuries or disabilities.*

Mental Health & Psychological Safety

Have you ever been diagnosed with or experienced any of the following? (Check all that apply)

Schizophrenia

Psychosis / Psychotic Breaks

Bipolar 1

Bipolar 2

Personality Disorder

Dissociative Identity Disorder (DID/MPD)

Other

None of the above

Please provide details about any diagnoses or experiences checked above.

Have you ever experienced hallucinations, dissociative events, blackouts, or paranoid thoughts?*

Yes

No

Please provide details about your hallucinations, dissociative events, blackouts, or paranoid thoughts.*

Have you ever been hospitalized for mental health reasons?*

Yes

No

Please provide details about your hospitalization(s) for mental health.*

Are you currently experiencing suicidal ideation, or have you in the past 12 months?*

Yes

No

Please provide details about your experiences with suicidal ideation.*

Are you currently taking any psychiatric medications?*

Yes

No

Please list all psychiatric medications you are currently taking, including dosage and frequency.*

Family History — Do any close blood relatives have a history of the following? (Check all that apply)

Schizophrenia

Psychosis / Psychotic Breaks

Bipolar 1

Bipolar 2

Epilepsy or Seizures

Heart Attack

Stroke

Aneurysm

Other

None of the above

Please provide details about any family history conditions checked above.

Substance Use

Do you currently use any recreational substances, including alcohol or cannabis?*

Yes

No

Please list all substances you currently use, including frequency and approximate amounts.*

Have you ever had any psychedelic experiences in the past (recreational or guided/clinical)?*

Yes

No

When was your last use of a psychedelic or entheogenic substance? (approximate date or timeframe)*

Have you ever had a difficult, distressing, or challenging psychedelic experience?*

Yes

No

Please describe your difficult or challenging psychedelic experience(s).*

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