Name
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First Name
Last Name
Email
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Date of Birth
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Physical and mailing address if different from physical
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Please give a brief explanation of why you are seeking services at this time
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Primary Language
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Relationship status
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Current Employment
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If you are not currently working, please give your previous occupation.
Have you ever worked with a therapist?
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If yes, for how long and when was your last contact?
Are you currently seeing a psychiatrist?
If yes, please explain for how long and any past or current medications
Have you ever received a mental health diagnosis?
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If yes, please describe
Have you ever identified as feeing suicidal or actually attempted suicide?
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If you answered yes, please give a brief explanation.
Do you have sleep issues?
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Check all that apply.
Do you have issues related to food?
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Please check all that apply
Do you have issues related to sexual function?
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Have you had a full physical exam, including blood work, done in the last 12 months?
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Have you recently experienced a significant life-trauma (i.e. death of a loved one, loss of a job, loss of a significant relationship, loss of employment, financial stress etc..)?
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Have you ever been mentally or emotionally abused?
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If you are not sure, please answer yes and I will know to ask you more about it.
Have you ever been physically abused?
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If you are not sure, please answer yes and I will know to ask you more about it.
Have you ever been sexually abused?
If you are not sure, please answer yes and I will know to ask you more about it.
Have you ever been the victim of religious abuse?
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If you are not sure, please answer yes and I will know to ask you more about it.
Have you ever been involved in or exposed to a domestically violent relationship?
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If you are not sure, please answer yes and I will know to ask you more about it.
Have you ever had any involvement with Child Protective Services (CPS), either as an adult or a child?
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Please answer yes if it has involved you as either a child or as an adult.
Do you have any current or past medical issues or trauma?
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If you answered yes to any of these above 8 questions, please give a brief explanation.
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Do you frequently feel depressed?
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Do you frequently feel anxious?
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If you answered yes to either of these, please describe how it impacts your life
Do you currently have or do you have a history of problems with drugs, alcohol or other addiction that has disrupted your life?
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If yes, please give a brief explanation
Please rate your general life-satisfaction on a rating scale of 1-10, 1 being, "not at all," and 10 being, "fully satisfied."
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If you are seeking Psychedelic related therapy, please give a brief description of your desires for service.