Psychedelic Therapy Patient Intake Questionnaire Form
Please complete the Psychedelic Therapy Patient Intake Questionnaire Form to help us understand your needs and preferences for your upcoming session.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your primary reason for seeking psychedelic therapy?
*
Have you previously participated in any form of therapy?
*
Yes
No
Do you have any prior experience with psychedelic substances?
*
Yes
No
Please list any current medications or supplements you are taking (if any).
How would you describe your general mental and physical wellbeing?
*
Preferred session times (select all that apply)
Weekday mornings
Weekday afternoons
Weekday evenings
Weekend mornings
Weekend afternoons
Weekend evenings
Other
Submit
Should be Empty: