Mind-Body MEDICINE Assessment Form

We appreciate your cooperation in answering the questions in this form as fully as you can. When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you!

** Allow about 15-20 minutes

** Make sure to finish in one sitting, and SUBMIT at the end, or your info may be lost.

This information will be kept strictly confidential. Your personal information is collected for the purpose of supporting you properly and for administrative purposes. It will not be disclosed for other purposes without your consent.

Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

We would love to learn some more about you to allow us to better support you in this process. Please write a short response to each of the following questions. We invite you to give yourself a few moments to sit with the question and share from your heart.

Do you have previous experience of journey work? Please share the broad details without using any identifying terms or names:

Describe any particular life circumstances that brought you to this work:

Do you have someone who can pick you up and be available to help you after your session?

Do you have someone who can you reach out to for help in integrating what you’ve experienced during your session?

Please note the main CONTRAINDICATIONS for most sacred journey work are: MAOIs, Antidepressants, Antipsychotics, excessive Antihistamine use, Heart Arrhythmia, Uncontrolled Hypertension, and previous Seizure issues.

Please be honest in the section below, as it will not necessarily preclude you from working with us, it will simply involve clarifying which approaches might be best for you, or what work we need to do before a session. Dishonesty will put you and the facilitators at risk, and will not lay the proper groundwork for you to have a safe and energetically clear journey.

Please list any current significant physical health issues:

Are you taking any prescription medication for physical conditions? If yes, what kind and reason?

Please list supplements that are part of an ongoing regimen:

Please list any allergies that require regular treatment and medication:

Which of these physical symptoms do you experience?

Have you ever been diagnosed by a psychologist or psychiatrist with a ‘mental illness’ or DSM disorder (such as major depression, borderline personality disorder etc)? If so, what was the diagnosis and when did it occur?

Please list any current significant mental health issues:

Are you taking any prescription medication for psychological conditions? If yes, what kind and reason?

Please list any stimulant or recreational drug use. Type and frequency:

Have you ever considered suicide? If yes, please briefly describe:

9. Are you currently followed by a mental health professional or counsellor? If yes, what kind and reason?

I would rate my current stress/anxiety on a scale of 0-10 (10 being high)

if 0 don't click any stars

I have experienced the following:

Please comment on the most current significant source(s) of Stress and Anxiety

Which of these cognitive symptoms do you experience?

When you are stressed do you choose:

Do you take the edge off by:

Please provide any further details about your stress/anxiety and trauma history that you feel may be relevant.

How do you take care of yourself?

Who do you turn to for support?

Tell us about your strengths, hobbies, interests. What do you like to do for fun and relaxation?

Please describe your goals for this work:

Anything else you think we should know about you so we can provide you with the best support possible.

Today's Date

YearMonthDay

Signature (hold/click and sign with cursor)

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Participant Intake Form

ABOUT YOU

Let us learn more about your interest and support in doing this type of work

Pre-existent Medical & Mental Health Conditions

Mental Health, Stress, Anxiety & Trauma History

Support & Resources

Journey Goals

My signature below affirms that I have answered the above as truthfully and completely as possible: