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Satori Rx: Psychedelic Clinical Consult Intake Form

Please fill out the following form as completely as possible to help us understand your medical, mental health history, and substance use history and evaluate any potential risks of participating in a psychedelic experience. This form will be used for client informational purposes only and does not constitute medical advice or condone any illicit activity.

Basic Information

Name

Email

Phone Number

Age

Gender

Height (inches)

Weight (lbs)

Medical History

Do you have any allergies to food, medicines, or supplements?

Have you ever been diagnosed or suspect you may have any of the following medical conditions?

Have you ever been diagnosed or suspect you may have any of the following medical conditions?

Additional description of medical conditions:

Mental Health History

Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?

Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?

Please describe any mental health history, symptoms, or treatment details:

Have you ever experienced any of the following:

Have you ever experienced any of the following:

If you answered yes to any of the above, please provide an estimate of the dates of occurrences:

Do any of your family members suffer from severe mental illnesses such as schizophrenia, bipolar disorder, or any other serious condition? If so, please include details below:

Medications and Supplements

Prescription Medications

OTC medication, supplements, and herbal products

Substance Use

The following questions are intended to understand more about your history and relationship with various substances. Please answer these questions as truthfully as possible.

How often do you use alcohol?

If you use any nicotine or tobacco products, please describe the type of product, frequency of use, and length of use.

Have you used any of the following substances in the past 12 months?

Have you used any of the following substances in the past 12 months?

Further description of substances used, including most recent date of use, how much of each substance, and frequency of use:

Psychedelic Use History

Have you ever used a psychedelic substance previously?

Have you ever used a psychedelic substance previously?

Describe any past uses of psychedelics, including type, amount used, most recent date of use, and any negative or positive outcomes:

Current intention or desired outcome from psychedelic use:

Name of psychedelic guide or facilitator

Email of psychedelic guide or facilitator

Estimated date of psychedelic journey

Which psychedelic substance are you considering working with that you would like included in this review?

Would your like your guide or facilitator to receive a copy of these responses or your risk evaluation and harm reduction strategies?

Would your like your guide or facilitator to receive a copy of these responses or your risk evaluation and harm reduction strategies?

Other questions or topics for discussion:

Social History and Support Network

Relationship Status

Employment Status

Are there any major sources of stress in your life at the moment or recent events that have impacted your health?

Which of the following to you consider to be a part of your support system?

Which of the following to you consider to be a part of your support system?

Current Symptoms

Depression Symptom Severity (10 being highest)

Depression Symptom Severity (10 being highest)

Anxiety Symptom Severity (10 being highest)

Anxiety Symptom Severity (10 being highest)

Trauma Symptoms

Not at all
Several days
More than half the days
Nearly every day
Unwanted memories or reminders
Feeling on edge or overly alert
Avoiding thoughts, feelings, or situations
Sleep disturbance related to stress

Is there anything else you would like to mention?