First Name
*
Last Name
*
Date of birth
Email
*
Phone
*
What is your current occupation?
What are your hobbies/interests?
What are your current life challenges?
*
What are your current goals or aspirations?
*
Who are the people in your support network (friends, family, spiritual teachers, therapists, etc?) This is important for integration.
*
Is there any area where your network is lacking? *
Yes
No
Other
If you choose other, please put your response here:
Who can support you having this experience?
Are you currently taking any medications for the following? *
Depression (SSRIs, SNRIs, MAOIs, tricyclics)
Anxiety
Pain
Insomnia
High blood Pressure
Coughing
Heart
Any medications affecting the nervous system
Other
None of the Above
Please list ALL medications and dosage below. Over the counter as well please*
Are you allergic to any medications?
*
Have you recently stopped taking depression medication or mood stabilizers? If yes, please specify the medication and last intake.
*
Have you ever been diagnosed with a life threatening illness? Please provide details.
*
Do you currently have, or have you ever had, any of the following mental health diagnoses or symptoms
*
Personality Disorder
Schizophrenia
Depression
Anxiety
PTSD
Addiction
Compulsive Behavior
Bi-Polar
Suicidal Thoughts
Psychosis
None of the Above
Other
If you checked yes above, please provide more details here. When were you diagnosed? Are you currently seeing a psychologist/psychiatrist?
*
Cardiovascular & Neurological Health - Have you ever been diasgnosed with or currently have any of the following:
*
Heart Disease
Heart Attack
Heart Murmurs
Arrhythmias
High Blood Pressure
Stroke
Aneurysm
Seizure
Epilepsy
Fainting
Unexplained loss of consciousness
Other Cerebrovascular Disorders
OTHER
None of the Above
If you checked yes, please go into detail
WOMEN: Are you pregnant or trying to become pregnant? Are you currently breastfeeding? When was your last menstrual cycle?
Trauma History
*
Childhood trauma or adverse childhood experiences
Emotional Abuse
Physical Abuse
Sexual Abuse or Assault
War, Displacement, or Refugee experiences
Domestic Violence
Medical Trauma (surgeries, chronic illness, invasive procedures)
Loss of Parent or Partner
Accidents or Serious Injuries
Natural Disasters or Environmental Trauma
Religious or Spiritual Trauma
Workplace Trauma or Harassment
None of the Above
Other
If you checked yes above, please provide more detail here. The more detail you provide here the better. There are levels of trauma that must be assessed before working with bufo alvarius.
*
Emergency Contact Information (Please provide 2 contacts)
*
Do you actively use:
*
Cocaine
Amphetamines
Caffeine
MDMA (ecstasy)
Ayahuasca
Cannabis
Alcohol
2CB
None of the Above
Other
If yes to any of the above, please share how often and how much you use.
*
Do you have experience working with the following?
*
Ayahuasca
N-N-DMT
5-MeO-DMT (synthetic)
Bufo Alvarius (natural)
Kambo
Peyote
Iboga
Magic Mushrooms
None of the Above
Other
If yes to any of the above, how many times have you participated in these medicines, when, and what were the doages?
*
Is there anything else of importance you feel like we should know?
*
Lastly, what is your intention for seeking entheogenic assisted therapy at this time?
*
