Trauma-Informed Approach to Psilocybin Integration & Meditation

Screening Questionnaire for Psychedelic Integration TreatmentS

- Step 1 of 13

Completion Time Advisory: Please note, this form may take up to 30 to 45 minutes to complete. We recommend filling out this screening questionnaire at your own pace. Your information will only be submitted after clicking the final submission button. Please note that refreshing the page may result in losing the information you've entered in the form.

Segment 1: Client Information

1.1 Personal Information

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Full Name: *

Preferred Name:

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Date of Birth: *

Gender: *

Pronounces: *

Weight in kg: *

(to determine the dosage of Psilocybin)

Height in cm: *

(to determine the dosage of Psilocybin)

Nationality: *

Country of Residence: *

Contact Number: *

Email: *

Confirm Email

Residential Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Postal Address *

The same as Residential Address.
Different from Residential Address.

Postal Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency contact details in case of a medical emergency, psychiatric needs, or other urgent concerns. By filling out the emergency contact details, you provide us permission to contact this person accordingly if necessary.

Emergency Contact Name: *

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Emergency Contact Relationship: *

Emergency Contact Number: *

1.2 Demographics

Purpose: This section helps us identify and communicate with you effectively while respecting your cultural, and religious backgrounds and language preferences. We request information about your ethnic background and religious beliefs to provide culturally sensitive and personalized support during the psychedelic integration process. This information helps us understand your unique beliefs, values (Cultural Sensitivity and Tailored Support Beliefs about Healing and Psychedelics), and potential ancestral trauma that could influence your experience. Additionally, certain ethnic backgrounds have genetic predispositions that affect the metabolism of psychedelics (Risk Identification and Safety Measures Pharmacogenetics and Metabolism), enabling us to take safety measures to ensure your well-being.

If you would like to further understand the implications of why we gather this information please visit:

Cultural Considerations in Psychedelic Therapy (MAPS Article).

Racial/Ethnic Differences in Psychedelic Therapy Outcomes (Journal of Psychedelic Studies)

Language(s) Spoken: *

Separate more than one languages with a comma (,).

Ethnic Background in case we need to be aware of any sensitive personal preferences (optional):

Religious preferences (optional):

Segment 2: Mental and Emotional Health

2.1 Mental Health History

Have you been diagnosed with any mental health conditions? *

Please specify:

Depression
Bipolar Disorder
Anxiety Disorders
PTSD
Schizophrenia or Schizoaffective Disorder
Substance Use Disorder
Dementia
Borderline Personality Disorder
Obsessive-Compulsive Disorder (OCD)
Eating Disorders (e.g., Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder)
Autism Spectrum Disorder (ASD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Panic Disorder
Generalized Anxiety Disorder (GAD)
Social Anxiety Disorder
Agoraphobia
Specific Phobias
Somatic Symptom Disorders
Dissociative Disorders
Sleep Disorders (e.g., Insomnia, Narcolepsy, Sleep Apnea)
Chronic Pain Disorder
Psychosomatic Disorders
Adjustment Disorder
Conduct Disorder
Oppositional Defiant Disorder
Antisocial Personality Disorder
Traumatic Brain Injury (TBI)
Others

Please specify here: *

Are you currently under the care of a mental health professional? If yes, provide details: *

Name: *

First

Last

Specialty and Designation: *

Contact Information: *

If you may not have been diagnosed yet, do you have reasons to believe that you may be experiencing any mental health conditions?

Please specify:

Depression
Bipolar Disorder
Anxiety Disorders
PTSD
Schizophrenia or Schizoaffective Disorder
Substance Use Disorder
Dementia
Borderline Personality Disorder
Obsessive-Compulsive Disorder (OCD)
Eating Disorders (e.g., Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder)
Autism Spectrum Disorder (ASD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Panic Disorder
Generalized Anxiety Disorder (GAD)
Social Anxiety Disorder
Agoraphobia
Specific Phobias
Somatic Symptom Disorders
Dissociative Disorders
Sleep Disorders (e.g., Insomnia, Narcolepsy, Sleep Apnea)
Chronic Pain Disorder
Psychosomatic Disorders
Adjustment Disorder
Conduct Disorder
Oppositional Defiant Disorder
Antisocial Personality Disorder
Traumatic Brain Injury (TBI)
Others

Please specify here: *

2.2 Current Symptoms (if any):

In the past month, have you experienced any of the following: *

Persistent sadness or low mood
Loss of interest in activities
Excessive worry or anxiety
Panic attacks
Intrusive memories or flashbacks
Difficulty concentrating
Mood swings
Suicidal or homicidal ideations
Self-harm urges
Anger management issues
Sleep disturbances (insomnia, nightmares)
Other
I have not experienced any of the mentioned options.

Please specify here: *

2.3 Medications and Treatment

Purpose: Understanding your mental health history and current state will help us tailor our integration approach while ensuring your safety avoiding any undesired drug interactions with Psychedelics.

Are you currently taking any medications for mental health conditions? If so, please list: (Please write as a list separated by commas in the respective order for each field below)

Medication/s: *

Dosage/s: *

Prescribing Doctor/s: *

Have you been hospitalized for mental health issues? *

Are you currently undergoing any form of therapy or counseling? *

Please specify: *

Segment 3: Past Trauma and Adverse Childhood Experiences (ACEs)

Purpose: Identifying past trauma and ACEs allows us to approach your healing journey with sensitivity and awareness of your personal history.

3.1 Childhood and Developmental History

Did you experience any of the following during your childhood or adolescence? *

Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Household Dysfunction (substance abuse, mental illness, incarceration)
Other
No, I have not experienced any of the above options.

Please specify: *

3.2 Traumatic Experiences

Have you experienced any traumatic events as an adult? If yes, please describe: *

How do you feel these experiences impact your daily life today? *

Segment 4: Current and Past Psychedelic Use

Purpose: Understanding your history and current use of psychedelics will help us assess your suitability for the treatment, and dosages and guide your integration.

4.1 History of Psychedelic Use

Have you used any of the following psychedelics? *

LSD
Psilocybin (Mushrooms)
Ayahuasca
DMT
Mescaline (Peyote/San Pedro)
MDMA
Ketamine
Other

Please specify: *

Last time you used: *

First time (approximately): *

Were you guided by a professional during any of these sessions? If yes, please provide further details. *

The purpose of use: *

Recreational
Self-guided Therapeutic Experience
Guided Session
Micro dosing

4.2 Current Psychedelic Use

Are you currently using any psychedelics? If yes, provide details: *

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Substance: *

Dosage: *

Frequency: *

Purpose: *

Segment 5: Physical Health

Purpose: Your physical health is crucial for safe participation. Identifying conditions that could pose a risk during the treatment will help us mitigate potential issues.

5.1 General Health

How would you describe your overall physical health? *

Do you have any medical conditions we should be aware of? If yes, please specify: *

Do you have any allergies (e.g., food, medications, substances)? *

5.2 Specific Health Concerns

Do you have a history of: *

Heart Disease
High Blood Pressure
Diabetes
Seizures or Epilepsy
Stroke
Chronic Pain
Respiratory Issues
Liver or Kidney Disease
Brain Injury
Recent Surgery
Other
No, I don't have a history of any medical conditions.

Please specify: *

5.3 Substance Use History

Do you currently use any of the following substances? If yes, specify frequency and quantity:

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Tobacco: *

Frequency of Usage: *

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Alcohol: *

Frequency of Usage: *

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Cannabis: *

Frequency of Usage: *

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Prescription Drugs (e.g., painkillers, sedatives): *

Frequency of Usage: *

Other substances (please specify):

Please put N/A if not applicable.

Segment 6: Contraindications for Psychedelic Use

Purpose: These questions ensure that those with specific conditions or risks are carefully assessed before entering the treatment.

6.1 Absolute Contraindications

Have you been diagnosed with or currently experiencing: *

Active Psychosis
Bipolar Disorder (Manic Phase)
Unstable Cardiovascular Condition
Severe Liver or Kidney Impairment
Pregnancy or Breastfeeding
I have not been diagnosed or am experiencing any of the above options.

Are you currently taking any monoamine oxidase inhibitors (MAOIs)? *

If you are unaware of MAOIs, feel free to inquire during the initial consultation.

6.2 Relative Contraindications

Have you experienced severe psychological distress or suicidal ideation in the past six months? *

Do you have any history of substance misuse or addiction? *

Segment 7: Intentions, Goals, and Ability to Strategize

Purpose: This segment helps us understand your ability to reflect, strategize, and follow through with an action plan, which is crucial for a successful integration journey as the healing and development through psychedelic integration emerge through innate awareness.

7.1 Personal Objectives

What are your intentions for joining the Psychedelic Integration Treatment? *

What specific outcomes are you hoping to achieve? *

How do you envision (or desire to envision) your life post-integration? *

7.2 Ability to Reflect and Strategize

How would you rate your ability to reflect on past experiences and strategize an action plan? (1-10 scale) *

Can you describe a time when you successfully planned and followed through on a significant change in your life? *

What challenges do you anticipate during the integration process, and how would you address them? *

Segment 8: Healing Space and Support Network

Purpose: Having a supportive environment and network is essential for successful integration. This segment helps us understand how we can best assist you.

8.1 Living Environment and Healing Space

Do you have a conducive space for healing and reflection in your daily life? If yes, please describe it: *

Are there any factors in your living environment that could hinder your healing process (e.g., triggers, stressors)? If yes, please specify: *

How can we support you in creating a healing environment? *

8.2 Support Network

Do you have a support network (friends, family, community) that can assist you during the treatment? *

How can we best support you in achieving your goals? *

Segment 9: Responsibilities and Expectations

Purpose: This final segment ensures you are fully aware of the responsibilities and potential changes you may face during and after the treatment. If you have any concerns and you would like to request a consultation before you move forward, schedule a consultation here.

9.1 Personal Responsibility and Understanding

Are you taking full responsibility for all outcomes, before, during, and after the Psilocybin Sessions? *

Do you confirm your understanding that this treatment uses Psilocybin as a natural herbal catalyst to create an experience of altered states of consciousness (Mystical Experience) for your healing and developmental needs? *

We will welcome all your questions before and during the treatment period. However, do you understand that these treatments are not intended as an academic or educational program on Psilocybin nor their usage in depth? *

Do you agree to reassess your mental health once again prior to the Psilocybin Session and inform us if there may be any shifts? *

Do you agree to reassess your mental health once again after the Psilocybin Session and inform us immediately if there may be any shifts? *

While Mystical experiences are common during the Psychedelic Application, are you aware that this treatment cannot guarantee a 'Mystical Experience' as the effects of Psilocybin are subjective to the individual, dosage, set/setting, and various other factors? *

9.2 Navigating Potential Changes

Are you aware that we are only able to support you through the integration within the treatment period that you have opted for? *

Are you aware that if you needed further therapeutic assistance, it would incur fees? *

Are you able to take full responsibility and navigate through potential changes in your formal and informal relationships influenced by this experience (we will support you mentally and emotionally during the treatment period)? *

Are you in good financial standing and able to support yourself if the need to take time off work arises? *

Are you able to take full responsibility and navigate through potential life-changing decisions influenced by this experience? *

Are you able to financially support yourself through the treatment journey? *

9.3 Continuation in the Treatment

Are you currently microdosing any Psychedelic? If yes, please specify:

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LSD *

What is the size of the microdose in milligrams? *

Reason for microdosing? *

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Psilocybin *

What is the size of the microdose in milligrams? *

Reason for microdosing? *

Others (please specify):

What is your preference for receiving conversational therapeutic sessions (preparation and integration)? *

Are you aware of the importance of attending all the Preparation Sessions and Integration Sessions as scheduled for the success of desired outcomes?

Your preferred method intaking Psilocybin (ingestion or ceremony): *

We deliver Psychedelic Application in the following countries. Please select your main preference: *

We use a blend of sensory experiences in a therapeutic and clinical setting to enable you to dive into the Psilocybin experience. We shy away from overstimulation of sensory and ritualistic practices and rather focus on inner work. How do you prefer us to prepare your Psilocybin ceremony? *

Acknowledgment:

Thank you for taking the time to answer these questions thoughtfully. If you have any specific questions you'd like to clarify, feel free to reach out via email or schedule a consultation. We will get back to you with an update within 3 business days. We look forward to supporting you on your journey of healing and transformation.

Signature of Client: *

Clear Signature

Date Signed: *

By submitting this form, you confirm the information is accurate and the digital signature signifies the permission to process your data accordingly. Upon submission, you will receive a copy of this form via email.

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