Initial Assessment and Health Overview (Part 2)

- Step 1 of 4

Information

To ensure that you have the best possible experience during your medicine Ceremony, we would like to have some more information about your medical history, medication and any supplements. The information you provide will help us determine the appropriate dosage of the medicine and assess whether it is safe for you to undergo a psychoactive journey. It is crucial that you provide this information honestly and in its entirety. Failing to do so can significantly impact your journey, overall well-being and even your life. Please inform us if you have ever experienced or are currently dealing with a physical or mental health condition, regardless of whether or not you are taking medication for it. In most cases, it is usually safe for you to continue your normal medication, but it's important to discuss this with us beforehand. By providing us with accurate and complete information, you allow us to ensure your safety and maximize the benefits of your experience.

Personal Information

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Personal Information

This section of our application seeks to understand you more as a person and perhaps, any trauma history which could arise during the plant medicine ceremonial experience. We ask these questions to provide the highest care for you, which is of integrity to our values. This information is confidential and will only be shared with our team of facilitators, support people, integration coaches and therapists. Please be honest and truthful as this will help us to support you in the best way possible.

What stories have you heard about your birth and peri-natal history? According to your caretakers, was it:

Easeful and free of interventions
Relatively smooth with some interventions
Complicated and risky
I don’t know
Other

If so, please explain:

Were you born prematurely?

If so, how long and what were the circumstances?

Did you have any medical interventions as an infant and toddler?

If so, please list them.

What do you remember your childhood and home environment being like from the age of 0 - 5 years of age? Was your childhood and home:

Safe and secure, with mostly supportive and happy memories.
Inconsistent, with some memories of safety and security, and other memories of abandonment, neglect and inconsistent care, but mostly pleasant memories.
Scary and fearful, and mostly unpleasant memories.
I can’t remember.
Other

If so, please explain:

Do you remember any childhood traumatic experiences which happened to you during this time?

If so, what were they?

What do you remember your childhood and home environment being like from the age of 6 - 18 years of age?

Safe and secure, with mostly supportive and happy memories.
Inconsistent, with some memories of safety and security, and other memories of abandonment, neglect and inconsistent care, but mostly pleasant memories.
Scary and fearful, and mostly unpleasant memories.
I can’t remember.
Other

If so, please explain:

Do you remember any childhood traumatic experiences (Physical, emotional, psychological, sexual, medical, environmental, societal) that happened to you from 6 - 18 years?

If so, what were they?

Tell us briefly about your family.

What is your current life situation?

Please provide details.

What are some of the activities that bring you joy and pleasure?

Please share a difficult experience that you were able to overcome. What were some tools which helped you to overcome your experience?

Have you ever been or are you in an abusive relationship?

If you do not have access to follow-up therapy after this ceremonial experience, what do you plan to do to support yourself after?

Psychological Health

It is important to ensure your safety whilst on retreat that we have full knowledge of any psychological health conditions you are currently experiencing or have had in the past. Please be as honest as possible when answering the following questions. You can be assured that your information will remain confidential and is used to provide you with proper care.

Have you had or do you currently have any mental health challenges?

Please circle check for present or past conditions if not sure leave blank:

Anxiety Disorder
Bipolar Disorder
Depression
Psychosis
Schizophrenia
Serious mental health problems (excluding depression and anxiety).
Paranoia
Panic Attacks
Autism
Asperger's
Attention Deficit Disorder
Attention Deficient Hyperactive Disorder
Obsessive Compulsive Disorder
Suicidal Ideation(Thoughts/Attempts at suicide)
Eating Disorder
Borderline Personality Disorder
Depersonalisation Disorder
Multiple Personality Disorder
Self-Harm
PTSD

Please provide any other information you think might be relevant:

Have you ever been hospitalised or received therapy for the above conditions?

Please describe in detail:

Are you currently receiving therapy or attending any support groups?

Please describe in detail:

Are you currently taking or have you ever been prescribed any medications for these conditions?

Please describe in detail:

Do you have a family history of the above conditions?

If so, please specify which family members, which conditions and the current state of health of those family members, and how their condition has affected you.

Please provide any other information you think might be relevant:

Thank You!

Thank you for taking the time to complete this part of the intake. It will help us to work safely with you and to optimise the support we can offer you.

Disclaimer

You are advised to take full responsibility for your own health. All information provided is for informational purposes only and is not intended to be taken as healthcare advice, medical diagnosis, treatment or prescription. None of the information should be regarded as a promise of benefits, a claim to cure any illness, disorder or discomfort, a legal warranty or a guarantee of results to be achieved. Neither is this information intended as a substitute for advice from your physician or other healthcare professionals. You are advised not to use this information for the diagnosis or treatment of any health problem or for prescription of any treatment, including medication. Before altering or stopping any current medications, courses of treatment or medical care, starting any diet, exercise or supplementation program, you should consult with a healthcare professional. If you have, or think you might have, a health problem, your healthcare professional should be consulted.

Agreement and Informed Consent

I will disclose all prescribed medications, medical treatments, or therapy I am taking or undergoing.
I will discontinue all use of alcohol, marijuana, recreational, street drugs and non-prescribed pharmaceuticals at least three weeks before commencing with GOA. Many street and recreational drugs are strongly contraindicated and can be dangerous and potentially fatal.
I have read, understand and will comply with the medical guidelines and our safety policies.
I have read and understood the information in this medical form.
I have answered all the above questions fully and honestly and have not withheld any information that could be important.

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