First & Last Name:

Preferred Pronouns:

Email:

Phone Number: 

Marital/Relationship Status and partner's name (if applicable)

Names and ages of any children

Where do you live, and what time zone are you in?

Postal Address

Date of Birth

Are you working, and if so, as what?

Website and/or Social Media addresses (if applicable)

Emergency Contact and relationship to contact

Body Weight (for dosage)

Dietary Restrictions

How did you hear about me?

What are your long term goals?

Why are these important to you?

How will you feel once these goals are achieved?

What's currently holding you back?

What does success in our work together look like to you?

Family of origin (parents and siblings), historically and in the present. What are the key roles, dynamics, stories and wounds, as well as areas of strength and empowerment.

What are the close relationships in your life currently, family and other? Are they challenging? fulfilling? and why?

Please describe any past or current therapeutic experience. What themes have been you been working with, and with what (if any) specific modalities?

Do you have prior experience with MDMA?

If so, please describe the date(s), circumstance, experience, and dosage (if known)

Do you have prior experience with psilocybin mushrooms?

If so, please describe the date(s) circumstances, experiences, and dosage (if known)

Do you have prior experience with LSD?

If so, please describe the date(s) circumstances, experiences, and dosage (if known)

Do you have prior experience with Ketamine?

If so, please describe the date(s) circumstances, experiences, and dosage (if known)

Do you have prior experience with any other plant medicines or psychedelics?

If so, please describe the date(s) circumstances, experiences, and dosage (if known)

Do you use Cannabis?

If so, please describe how often, in what circumstances, preferred method of intake, and any strain preferences 

From your experience, how would you describe yourself:

I - Lightweight. A little bit goes a long way with me.
II - Average, as far as I can tell.
III - I can take a lot, more than average

Have you been diagnosed with, or hospitalized for, psychiatric treatment including a manic-depressive disorder, a psychotic break or depression?

Are you presently on any MAOIs or anti-depressants?

Examples - Nardil (phenelzine), Parnate (tranylcypromine), Marplan (isocarboxazid), Eldepryl (l-deprenyl), and Aurorix / Manerix (moclobemide)

Have you been on any MAOIs or anti-depressants in the past? If so, please list dates and dosages.

Important:

Are you currently on any medications or supplements?

If yes, please list all medications and supplements you are taking, your dosage, and for how long you have been taking each. 

Do you have prior experience with any other plant medicines or psychedelics?

In what ways do you nurture your spiritual and personal growth and development?

What regular practices support you in this (mindfulness, physical, religious, etc.)?

What is your intention for doing this work and what is calling you to this sacred container? 

What are you grateful for?

What do you value the most in your life?

Is there anything else you would like me to know about you to help me to support you in the best way possible?

Have you experienced any past instances of sexual trauma or abuse? Please provide a brief description or any relevant details if you feel comfortable.

Are there specific triggers or concerns related to past sexual trauma that you want me to be aware of during your Medicine Journey?

Have you ever struggled with addiction, either to substances or behaviors? If so, please specify the type of addiction, and if you're comfortable, describe your journey in overcoming it.

Are there any current challenges or concerns related to addiction that you would like us to consider during your Medicine Journey?

Do you have a support system in place for dealing with any emotional challenges or traumas that may arise during or after the Medicine Journey? Please share any details about your support network, if applicable.

How do you envision your Medicine Journey assisting in your healing journey, particularly concerning past trauma or addiction? What are your primary intentions and expectations for this journey?

Have you previously received therapy, counseling, or medical treatment related to your past trauma or addiction? If so, please provide relevant details and the name of your healthcare providers, if possible.

Is there any other information or considerations you believe would be helpful for us to know as we support you in your healing journey during your Medicine Journey regarding any sexual trauma or addictions?

(When in person) Are you interested in receiving energy work from Sand? 

Note: this may include physical touch

Do you have any irritations or allergies related to burning plant matter (sage, palo santo, etc.)?

What is your preferred choice of electrolytes?