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 Psychedelic Medicine 
Intake Questionnaire

Do you have any medical conditions that you know of that may have compromised the function of your liver, such as hepatitis, HIV, sclerosis, or cirrhosis or have you ever had a liver panel test conducted?
Do you have any heart conditions that you know of (no matter how minor) or have you ever had an EKG conducted?
Do you have any known allergies to food, medication, or different environments?
Are you a veteran?
Have you ever been incarcerated?
Do you currently use any form of tobacco?
Do you currently use any form of cannabis?
Do you drink alcohol?
Have you had a process addiction or other compulsive disorder that negatively affected your life, such as gambling, anorexia, bulimia, or excessive pornography?
Have you ever been a patient in detox, a rehabiliation center, or any other sort of drug treatment program, to include outpatient care?
Have you ever attended twelve-step meetings or any other support group?
Do you have any family members that are supportive of your recovery?
Are you currently taking any medication for psychological conditions, such as anti-depressants, mood stabilizers, lithium, anti-psychotics, or any other medication prescribed by a psychiatrist or physician?
Have you ever received any form of mental health treatment, whether inpatient, outpatient, or for evaluation purposes?
Have you ever considered hurting yourself or someone else?
Are you a survivor of any form of sexual assault or abuse?
Are you a survivor of childhood abuse, neglect, or abandonment?
Have you ever used psychedelics before?
Do you have any physical limitations that may limit your participation or that will require special accomodations?
Thank you for your submission!
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