Journey Intake Form

Please answer this form as thoroughly as possible. It is very important to communicate any medical conditions, medications, supplements, life experiences or habits that could influence your journey. The highest intention is for you to have a safe and transformative experience.

This information is considered strictly confidential.

First name

Last name

Birthday

Address

Phone

Email

How were you referred?

What are your reasons, hopes or expectations for doing this work?

What are your concerns or fears?

Are you experienced with work of this nature? If so, please share about your past experiences, types or any other relevant details.

Please share about any challenging experiences you may have had in the past doing this work or similar work.

In general, how satisfied are you with your life?

Very satisfied

Somewhat satisfied

Somewhat disappointed

Very disappointed

Do you experience anxiety in your life?

Do you experience depression?

Do you experience hopelessness?

Do you experience loneliness?

Do you experience angry outbursts?

Do you get stressed easily?

Please describe any current or past psychological or psychiatric conditions/diagnoses you've had.

Have you ever had a psychotic episode or been hospitalized for a psychiatric condition? If yes, please give the dates and describe the circumstances.

Have you ever been abused: physically, mentally, emotionally or sexually? If so, please describe and current symptoms or effects.

Have you experienced other trauma? Please describe any treatments you have tried and current symptoms.

Are you now or have you ever been suicidal? If yes, please describe.

Please describe how you cope with stress and challenge in your life.

Considering your age, how would you describe your overall health?

Poor

Fair

Good

Excellent

Do you currently have any medical conditions? If yes, are you currently in the care of a health care professional? Please describe the conditions and current treatment.

Have you ever had a heart attack, stroke, heart disease, or high/low blood pressure? If yes, please explain.

If you have high blood pressure, are you taking medication? If so, for how long? What is your current BP on medication? What was your BP before taking medication. (Please skip if not applicable)

For females only - could you be pregnant?

Yes

No

Please list all Rx medications that you are currently taking. Include the dosage, what it is treating, and for how long you have been taking it.

Are you more or less sensitive to medications than most people? Do you experience side effects from medications or supplements? If yes, please describe.

Are you allergic to any medications? If yes, please describe.

Please describe your support network of family/friends and how they feel about your journey.

Are you currently employed, in school or retired?

Please describe your relationships with your family of origin - including parents, caregivers, siblings, step-family, etc.

What else do you want to share about yourself? Or what questions do you want to discuss?

All efforts are made to assure a safe and beneficial experience, yet there are risks associated with this work. Please provide the name, relationship and phone of trusted person should you need assistance getting home, or if an emergency arises.

I hereby confirm that I have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good.