Enfold Intake Form

Enfold 1:1 Session Intake Form

Please be as thorough and truthful as possible. All responses will be kept strictly confidential.

"*" indicates required fields

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General Background

Your Name*

First Last

Email*

Mobile Number*

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 Country

When are you coming to Enfold?*

Please share why you're seeking this experience or any intentions you have. Provide as much detail as possible.*

Psycho/Spiritual Background

Your 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

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

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

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

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

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

Yes

Other

Please provide as much detail as possible if you selected yes to either of the previous 2 questions*

Physical Health Background

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

Please provide details on your recent injuries or disabilities.*

Are you currently taking any medications?*

Yes

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

List the medications, including dosages, frequency, and how long you WERE taking them.*

Are you currently taking any vitamins or supplements?*

Yes

Please list the vitamins or supplements you are currently taking.*

Are you allergic to any medications?*

Yes

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

Please list the allergies that would require the use of an EpiPen.*

Are you currently pregnant?*

Yes

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 Information

What 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.

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?*

Yes

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

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

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 & Agreements

The 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. 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.

Please 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.