Name
*
First Name
Last Name
Gender and pronouns
Date of birth
MM
DD
YYYY
Location and time of birth (if known)
Occupation
What hobbies and activities do you enjoy outside of work?
Who do you live with? Please list relatives, children, spouses, roommates, and/or pets that share your home
Do you have any significant medical history? This includes any past medical emergencies, chronic pain or illnesses, mental health conditions, or other physical/mental/emotional issues that I should be aware of
Are you currently on any medications? If so, please list them along with what condition they’re prescribed for
Which of the following substances have you used in the past?
Are you a regular user of any of the above? If so, how frequently do you use?
Are you currently or have you ever struggled with addiction? If so, please explain
If you’ve ever used psychedelics, what have your experiences with them been like? If known, please also share the dosages you’ve taken
Do you have a history of trauma? This includes abuse, neglect, physical or sexual assault, serious accidents or medical events, serious illness, etc.
Are you currently or have you ever seen a therapist?
Who are the people in your emotional support system? This could include family, friends/chosen family, therapist or life coach, etc.
Do you have any spiritual practices, religious beliefs, or rituals that are important to you?
What are you hoping to gain from this experience with me? What areas of your life or yourself are you hoping to gain insight into or transform?
Is there anything negative that you hope to release or heal during our time together? Any pain, trauma, or limiting beliefs?
Do you have any fears or hesitations about having this experience with me?
Is there anything else you’d like me to know about you?