Please complete this autobiographical questionnaire as thoroughly as possible. It will take some time so please give yourself space/time. It is very important to be aware of any medical conditions, medications, supplements, life experiences, or habits that can influence your experience. Our interest is in helping you have a safe and beneficial experience. What you share in this form is a confidential record.

EMERGENCY CONTACTS. Please include the full name, phone number, email address, and relationship for each contact.

Why are you seeking this work at this time?

What are your goals, hopes, expectations?

What are your concerns or fears?

PREVIOUS EXPERIENCE WITH PLANT MEDICINES

Have you had a previous plant medicine experience?

YES

If so, what types of journeys have you experienced? (check all that apply)

If you answered "yes" to previous plant medicine experiences, please share a cliff notes version of these experiences below.

What insights have you had during these experiences?

Have you had any challenging or problematic experiences, either physical or psychological?

What influence have these experiences had on your life?

Please describe any concerns you have about doing these explorations.

In general, how satisfied are you with your life?

Very Satisfied

Mostly Satisfied

Somewhat Disappointed

Very Disappointed

If you have any of the symptoms below, please check the box that best describes their severity. If you don't have symptoms, leave blank.

Anxiety

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Hopeless Outlook

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Poor Memory

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Depression

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Lonely

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Dislike criticism

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Bad Temper

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Easily Stressed

Never

Mild/Sometimes

Moderate/Often

Severe/Constantly

Nervousness

Never

Mild/Sometimes

Moderate/Often

Severe/Constant

Do you self-identify as a highly sensitive person?

Yes

Do you self-identify as an empath?

Yes

Do you have any current or past psychological or psychiatric conditions or diagnoses (diagnosed or suspected)? If yes, please give the dates and describe the circumstances.

Do you currently see a psychiatrist, psychologist, or counselor? If so, who? How often and for how long have you been working together?

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

For the following questions, you only need to answer YES or NO. We can discuss further in our initial sessions.

Have you ever had a psychotic episode (lost touch with reality)?

Yes

Have you ever been abused?

Yes

If Yes, was the abuse:

Have you experienced big T trauma? (For example: Motor vehicle accidents, rape, mugging, robbery, being a witness to violence, etc.)?

Yes

Do you have any difficulty trusting others or life?

Yes

Do you experience fear or paranoia?

Yes

Have you ever been suicidal?

Yes

To what extent do you like yourself?

What do you not like about yourself?

What qualities do you especially admire in others?

What roles do you typically play in relations with other people?

What do you feel guilty about or ashamed of?

If you were listing three difficult feelings that most often arise in you, what would they be?

Are you happy with the amount of time you spend on social media or engaging with the news?

FAMILY: Current Family

Are currently in a romantic relationship(s), what type and how long?

On a scale of 1-10, how would you rate your satisfaction with your current relationship(s)? (1-low, 10-high): Please describe briefly your reason for choosing the rating you choose.

Who are the most important people in your life?

Who do you live with?

Do you have pets? If yes, please describe:

How supported by your family do you feel?

How much can you share about your personal process with your family and friends?

Do you feel comfortable asking your family for help if needed? Who is looking out for you?

Children, if any. (names and ages):

Are your parents living? If no, what age were you when they died?

If yes, do you currently have a relationship with them and how is it?

Are they separated? If so, what age were you when they separated? What was the custody arrangement?

Is there anything about your family of origin I should know about? (Neglect, violence, deaths, alcohol, religious oppression, absent parent, depressed parent, mentally unstable parent)

What was it like for you growing up?

Please list any family history of diagnosed or suspected psychiatric illness (depression, anxiety, bipolar, psychosis, borderline, mental health hospitalizations, etc.)

How would describe your overall health?

Excellent

Good

Fair

Poor

Do you have any current health concerns or issues?

Please list all prescription and over the counter medications that you are currently using regularly.

Please list all prescription and over the counter medications that you use on occasion?

Please list all supplements (vitamins, minerals or herbs) that you routinely use.

Have you had any adverse reactions/allergies to medications? If so, please describe.

Do you have any allergies?

Please list any major surgeries, hospitalizations or significant illnesses in your past, including approximate date.

What is your sensitivity to medications (for example, ibuprofen)

Do you have a history of cardiovascular disease?

Yes

Do you have a history of diabetes?

Yes

Do you have a history of heart rate/rhythm irregularity?

Yes

Do you have a history of high blood pressure?

Yes

Do you have a history of seizure disorder?

Yes

Do you have any breathing disorders, such as asthma?

Yes

Do you have any kidney disorders/irregularities urinating?

Yes

Do you have any history of liver disease?

Yes

If you answered yes to any of the above, please describe.

Please list any family history of cardiovascular disease (provide a brief description to the best of your understanding).

How would you describe your energy levels?

Low/Depleted

Variable/Inconsistent

High/Excess

Appropriate/Normal

How many days a week do you exercise?

Are you satisfied with your level of fitness?

Yes

What physical activities do you enjoy doing or are interested in?

Are you able to carry a bag of groceries up 1 flight of stairs without needing to take a break?

Yes

Do you experience any difficulties breathing or chest pressure or tightness when you exercise?

Yes

How would you describe your sleep patterns? What time do you go to bed and wake on average? What is the quality of your sleep?

How many hours of sleep do you usually get a night? Any trouble falling or staying asleep? If Yes, please describe.

Do you wake feeling refreshed?

Always

Usually

Rarely

Never

Please describe your current diet. Do you have any dietary restrictions or food allergies (please explain)?

How much water do you drink per day (ounces)?

How satisfied and nurtured do you feel by your current diet?

Very Satisfied & Nurtured

Mostly Satisfied & Nurtured

Somewhat Unsatisfied & Not Nurtured

Very Unsatisfied & Not Nurtured

SUBSTANCE USE HISTORY

How often do you use drugs, prescription medication, or any other consciousness-altering substances? Please describe your use of any substances throughout your life, and those you have used in the past three months.

Please indicate if you use any of the following:

Cannabis

Yes

Past

Caffeine

Yes

Past

Have you had any adverse reactions to alcohol, drugs, or any consciousness-altering substances? Please describe in detail the type of substance taken, when, how much (if known), the situation or purpose of taking the substance, and the adverse reaction.

Are you sensitive or tolerant to any substances? Have you had to take more or less of a substance than usual to experience an effect? If so, please describe.

Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe.

Do you have a support structure in your life? (i.e. Friends/family that you can call and rely upon for help and support) If yes, please describe:

How difficult or easy is it for you to reach out for support from your family and friends? And how easy or challenging is it for you to receive support when you need it?

How do you nurture yourself? What are your self-care practices?

What is your current career or work?

Briefly describe your education and professional background.

Have you changed careers in your life? If yes, please describe:

How satisfied are you with your current work?

Please explain why you gave the answer above:

Are you satisfied with your current sexual experiences? If no, please describe.

Is there any trauma that has been or needs to be healed that you are aware of?

Yes

CREATIVITY/SPECIAL INTERESTS

Do you feel connected to your creativity/curiosity/sense of play?

Yes

Apart from what you have already written about your education and your career, what interests do you have, even if you have not developed them as fully as you would like?

Do you have any creative outlets? Art, music, dance, etc.?

RELIGION/SPIRITUAL PRACTICES

Do you have a spiritual practice? Please describe.

How happy are you with your current spirituality?

Describe your religious beliefs, including concepts of God/higher powers, death, heaven and hell, ethics, and observances etc.

Was your family associated with one or more religions while you were growing up? If so, which ones? To what extent were they active? What effect did religions have on your development?

Have you had any mystical or spiritual experiences? If so, even if they were impossible to describe, what could you say at least to point someone else in the direction of what you experienced?

In additions to your answers so far, describe any other outstanding experiences, desires, interests, habits, beliefs, relationships, and feelings that have played a major role in your development.

This work may lead to profound shifts in your life and it is ideal to have a framework of resources in place ahead of time to support you before, during and after sessions. Having support to help you integrate the experience can help you to get the most benefit from the work. What friend, loved one, counselor or other trusted person(s) do you speak with about this work? What are their dispositions towards you in pursuing this work?

Is there anything else you would like me to be aware of or any specific questions you have?