Enfold Intensives Intake Form Please be as thorough and truthful as possible. All responses will be kept strictly confidential. "*" indicates required fields Step 1 of 5 20% General BackgroundYour Name* First Last Email* Mobile Number*We will reach out to you via WhatsApp using the number you list here. Please ensure you have the app installed and an account set up.Your Age*Preferred Gender Pronouns (Optional)Emergency Contact Information*Please list at least one and up to three emergency contacts. Include Name, Relationship, and Phone Number.Where do you live?*City, State, and CountryDid someone refer you to Enfold?If yes, who?Why are you seeking this experience?* General Mental Health Release Negativity Emotional Pain Physical Pain Physical Health General Past Trauma Mental Abuse Trauma Sexual Abuse Trauma Physical Abuse Trauma Addictions Wellbeing Life Purpose Career Change Learning Creativity Personal Growth Curiosity Grief or Loss Other Please elaborate if you selected 'Other'.*Please share more about why you're seeking this experience or any intentions you have. Provide as much detail as possible.* Psycho/Spiritual BackgroundYour safety and well-being are our highest priorities. It is essential that you provide complete and accurate responses to the following questions to help us ensure your well-being throughout this experience. Your honesty is crucial in creating a safe, supportive, and beneficial environment for yourself and others. Withholding or omitting information in this section may compromise your safety. If you are uncertain about any of the questions, please provide as much detail as possible. Answering in the affirmative does not mean you will be excluded from joining. Our team is here to support you and will follow up if further clarification is needed Answering in the affirmative does not mean you will be excluded from joining. Our team is here to support you and will follow up if further clarification is needed.Mental Health Issues*Select all that apply. If none, select NONE at the bottom. Please be thorough. Spiritual Crisis Mental Disorder Anxiety Disorder Clinical Depression Mild Depression Suicidal Ideation Eating Disorder / Bulimia / Anorexia Bipolar 1 Bipolar 2 Schizophrenia Psychosis Psychotic Breaks Personality Disorder Self Harming Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Attention Deficit Hyperactivity Disorder (ADHD) Dissociative Identity Disorder (MPD) Autism Alcoholism or Drug Addiction NONE Other Please provide details about any boxes checked above*Include diagnosis history, any past and current medications including dosage and time on medications.Have you ever been hospitalized for mental health reasons?* Yes No If yes, please provide details.*Do you have any current or past addiction issues or challenges with any of the following?*These could be self-diagnosed addictions or compulsive feelings. Alcohol Drugs Food Smoking Compulsive Shopping Sex Internet/Social Media/TV Pornography Exercising Gambling NONE Other Please provide details about any boxes checked above*Have you experienced trauma in your life?* Yes No I’m not sure What is your relationship with those experiences today?*Please provide as much detail as possible.Do you have a support system in place?* Therapist Psychiatrist Spouse Friends Family Spiritual Community Other None Can you share more about the support you currently have or have sought in the past?*Include the timeframe, duration of treatment, reasons for seeking support, and any other context you feel would be relevant. Please be thorough.Have you taken any psychiatric medications either in the past or currently?* Yes No Please list any psychiatric medications you've taken either in the past or currently.*Include the timeframe, duration, dosage, and how the medication impacted the symptoms you were treating.Describe the relationship you have with your mother and father, and any step parents that were present in your childhood/adolescence.*Please describe each relationship individually, as well as share any information about your parents relationship with one another.How was love expressed in your childhood/adolescence?*Do you have children?* Yes No What are their ages, and how are things going? What are the best and most challenging things happening in their lives? How do those dynamics affect you and/or your partner?*Describe any significant events, stressors, challenges, transitions, or situations happening in your life currently or in the last 12 months.*This could include work-related events, romantic relationships, children, spouses, parents, friends, traumatic events, financial or legal issues, major life changes, or anything else that comes to mind.What is your current relationship/marital status? If you're in a relationship, please provide basic details and describe the relationship from your perspective.*Your response to this question (and all questions) will not be shared with your spouse/partner. If you’re not in a relationship, please describe the last serious relationship you were in and when that was.Have you ever considered taking your own life?* Yes No Have you ever experienced hallucinations, dissociative events, blackouts, voices or paranoid thoughts?* Yes No Other Please provide as much detail as possible if you selected yes to either of the previous 2 questions*Have you ever experienced anxiety, fear, or distress related to sleeping or falling asleep?* Yes No Please describe your experiences, including any specific concerns (e.g., nightmares, sleep paralysis, fear of not waking up, or other sleep-related anxieties).* Physical Health BackgroundYour safety and well-being are our highest priorities. It is essential that you provide complete and accurate responses to the following questions to help us ensure your well-being throughout this experience. Your honesty is crucial in creating a safe, supportive, and beneficial environment for yourself and others. Withholding or omitting information in this section may compromise your safety. If you are uncertain about any of the questions, please provide as much detail as possible. Answering in the affirmative does not mean you will be excluded from joining. Our team is here to support you and will follow up if further clarification is needed.Height in Feet and Inches*Weight in Pounds*Physical Health Issues*CURRENT or PAST. Select all that apply. If none, select NONE at the bottom. Please be thorough. Diabetes Epilepsy or Seizures Obesity Visual Impairment Hearing Impairment Physical Disability Thyroid Conditions Fainting Infectious Disease Cancer Cardiac Issues Other NONE Please provide details about any boxes checked above*Include diagnosis history, any past and current medications including dosage and time on medications.Heart Health* High Blood Pressure Circulatory Problems Stroke Irregular Heartbeat Aneurism Heart Attack NONE Other Please provide details about any boxes checked above*Include diagnosis history, any past and current medications including dosage and time on medications.Have you suffered any recent injuries or disabilities?* Yes No Please provide details on your recent injuries or disabilities.*Are you currently taking any medications?* Yes No List the medications, including dosages, frequency, and how long you have been taking them.*Include any prescription medications, including GLP-1s.Have you taken any other medications in the last 6 months that you are currently NOT taking?* Yes No List the medications, including dosages, frequency, and how long you WERE taking them.*Are you currently taking any vitamins or supplements?* Yes No Please list the vitamins or 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 would require the use of an EpiPen.*Are you currently pregnant?* Yes No Possibly Do you have any history of any of the following conditions in your close family?*In addition to your personal history, it is important to consider any relevant mental health conditions within your family, as they may provide valuable insight into your overall well-being and potential risks. Please provide complete and accurate information about any history of mental health conditions, such as psychosis or schizophrenia, among your close relatives. Your honesty is crucial in helping us create a safe, supportive, and beneficial environment for you. Withholding or omitting information in this section may compromise your safety. Answering in the affirmative does not mean you will be excluded from joining. Our team is here to support you and will follow up if further clarification is needed. Please consider parents, siblings, first cousins, aunts and uncles. If none, select NONE at the end of the list. High Blood Pressure Circulatory Problems Stroke Heart Attack Irregular Heartbeat Bipolar 1 Bipolar 2 Schizophrenia Psychosis Anxiety Disorder Clinical Depression Dissociative Identity Disorder (MPD) Obsessive-Compulsive Disorder (OCD) Attention Deficit Hyperactivity Disorder (ADHD) Self Harming Suicidal Ideation Psychotic Breaks Personality Disorders Autism Aneurism Diabetes Epilepsy or Seizures Obesity Thyroid Conditions Alcoholism or Drug Addiction NONE Other Please provide details about any boxes checked above* Lifestyle InformationWhat do you do for work?*What is your relationship to your work?*Do you find it meaningful and purposeful? Do you enjoy it?List any recreational drugs you currently use, including alcohol. Include frequency, volume, and any other relevant information.*List anything you’ve taken in the last 90 days. Be thorough in terms of amounts and frequency. Enter NONE if none.Do you have a meditation practice or other regular mindfulness or reflective practices?*What personal or spiritual development (or however you'd define your inner work) have you done in your life?*This could be self-practice, reading, courses, workshops, extended programs, coaching, etc.Describe your current and past relationship with any specific faiths or religions.*Were your experiences primarily positive, neutral, or challenging? If applicable, did your upbringing in a faith-based environment involve fear, guilt, or pressure? Have any religious beliefs or experiences contributed to stress, anxiety, or trauma in your life? Please share as much detail as you feel comfortable.How would you describe your level of fitness and physical activity? (Please be honest!)* Not great, very little exercise or physical movement Mildly out of shape, exercise once in a while or get some regular walking in Average.. exercise a minimum of once a week Reasonable physical fitness – exercise two+ times a week Very good shape – exercise rigorously often How would you describe your regular eating habits and diet?*Do you have any food sensitivities, allergies, or restrictions we should know about?*We can easily accommodate vegan, gluten-free, and egg-free diets. If you have any other dietary restrictions, we’ll do our best to accommodate, but we may not be able to support all requests depending on the kitchen setup and resources available. If you have a scent sensitivity, please also let us know — scent is an intentional and important part of the experience, and while we’ll do our best to accommodate, some elements may not be adjustable. Yes No Please list your food sensitivities, allergies, or restrictions.*How much sleep do you get on average? Please describe the quality of your sleep.*Have you ever had any psychedelic experiences in the past? (Recreational or Guided/Clinical) Yes No Describe any psychedelic experiences you have had in the past.*Provide as much detail as possible.How do your psychedelic experiences typically go? Please describe the nature of your experiences the best you can.*Have you ever done a large or therapeutic dose of psychedelic or entheogenic medicine? Yes No When was the last time you did a large or therapeutic dose of psychedelic or entheogenic medicine?*Describe any past experiences with non-ordinary states of consciousness outside of psychedelics*(e.g., breathwork, meditation, fasting, extreme stress, sleep deprivation)What is your comfort level with surrendering control during altered states?* Extremely uncomfortable Somewhat uncomfortable Somewhere in the middle Pretty comfortable Extremely comfortable Disclosure & AgreementsThe following agreements are required to participate in the Enfold Intensive. Please read each one carefully, confirm your understanding, and check the boxes below. Disclosure Agreement*I have read and agree to the Enfold Health Screening and Full Disclosure. Because our meditations involve breathwork and other altered-state inducing practices, we carefully screen each guest for their safety prior to attending an Intensive. I confirm that: All information I have provided is accurate, current, and complete. I have disclosed all known physical and psychological conditions. I have disclosed all medications, supplements, and substances I’m currently taking or have taken in the past 12 months. I understand that a member of the Enfold team may contact me for follow-up if needed. I acknowledge that Enfold is not a medical facility, and that its team members are not licensed medical professionals. Enfold does not diagnose, treat, or cure illness. It serves as a facilitator of transformational work in a non-clinical setting. YES – I have read the Disclosure Agreement (above) and agree. NO – I have read the Disclosure Agreement (above) and do not agree. Guest Agreements*The following agreements help protect the safety, presence, and sacredness of the group container. Please read each one carefully and confirm your understanding. I understand that this is a fully device-free experience. I agree to surrender all phones and connected devices at check-in. An emergency contact number will be provided for loved ones. I understand that essential oils and incense are used throughout the week, particularly in ceremonies and shared spaces. A scent-free environment is not possible. I agree to refrain from alcohol, cannabis, and any unsanctioned mood-altering substances during the Intensive. I understand that all psychoactive substances used in ceremony are facilitated by Enfold. I have disclosed all prescription medications in my intake form. I agree to refrain from sexual activity during the Intensive. If I am attending with a spouse or partner, private, respectful intimacy in our room is welcome. This supports the integrity of the group container. I understand that Enfold accommodates vegan, vegetarian, gluten-free, dairy-free, and egg-free diets, and I have disclosed any additional dietary needs in my intake form. I accept that highly specialized protocols may not be supported. I agree to maintain confidentiality and will not record, photograph, or share any part of another guest’s experience—during or after the Intensive. I understand that this work asks for presence, honesty, and willingness. I intend to participate fully in all sessions and practices, and to show up as best I can. I understand that one day of the Intensive will be held in Noble Silence, and I agree to honour this as part of the process. Select AllPlease type your full name in CAPITAL letters to show that you understand the above and confirm your selection*Would you like an emailed copy of your intake form submission? Yes, send me a copy of my submission.
