Psychedelic Safety Questionnaire

Please complete this questionnaire before your upcoming journey

Psychedelic experiences are very safe, but they are not for everyone. None of the questions, except the first one about pregnancy, will automatically disqualify you from participating in psychedelic services and events as long as the service matches the standard of care required to support your safety.

This is an opportunity to discuss safety and help your guide create the necessary preparation, integration support, and the safest and most appropriate container for your experience. Participation agreements and informed consent documents will also be required to participate in any psychedelic experiences with us.

Contraindications (reasons not to participate in a psychedelic experience) will be included in the specific service’s participation agreement and listed throughout this intake form.

To get the most out of our time together, it will be useful for us to have as much background information as possible. Please feel free to share as much or as little as you would like to on this intake form, remembering that the more we know about you, the better we can support you through this transformative process. If there is an item you don't wish to go into at this time, write "decline" or if an item doesn't apply write "n/a."

All information provided is confidential. This questionnaire is used for both individual and group psychedelic sessions.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

City & State

Select

I am female

I am male

I am non-binary

Emergency Contact Name

Emergency Contact Phone Number

1. Are you pregnant or nursing?

2. Do you have any food allergies, or are you sensitive to incense or essential oils? (Please note: At the end of the session snacks may be provided to participants that usually include orange juice, chocolate, sometimes nuts, gluten-free pretzels, and strawberries or grapes. You are responsible for informing the guide(s) of any severe food allergies before the experience begins, and to take responsibility for any snacks you consume.)

If yes, please describe:

3. Do you have any past or present medical conditions (either physical or mental health) that may affect your ability to safely participate in this experience? A psychedelic experience is not appropriate for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy.

If yes, please describe:

4. Do you have any past (within the last two years) or present concerns around suicide or self-harm?

If yes, please describe:

5. Are you currently on any medications, supplements or recreational drugs that could affect you safely participating in a psychedelic experience?

If yes or maybe, please list all medications, supplements and/or recreational drugs:

6. Do you have a safe home environment and a generally stable residence, and are not subject to active or ongoing domestic violence? (Please note: Homelessness and not having a safe space to return to after a psychedelic experience may not provide the necessary setting for proper integration.)

If no, please describe:

7. Do you have any past or present severe mental health diagnoses that may affect your ability to safely participate in a psychedelic experience? A psychedelic experience is not appropriate for persons with any severe mental illness without significant specialized professional care, including but not limited to Psychosis or other psychotic disorders, Dissociative Identity Disorder (DID), any Personality Disorders, Bipolar Disorder and other Severe Mood Disorders.

If yes, please describe:

8. Do you have a history of traumatic or difficult life events that have not been addressed or are not being supported therapeutically? Severe trauma and PTSD is best supported in an individual setting rather than a group event.

If yes, please describe:

9. Have you ever required significant treatment or been hospitalized for a psychological or emotional disorder or for any psychological or emotional reason?

If yes, please describe:

10. Do you have a history of disruptive or violent physical, sexual, or emotional behavior?

If yes, please describe:

11. Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines, physically, emotionally, or otherwise?

If yes, please describe:

Anything else you think we should know about? Use the space to include any additional comments, questions, or concerns.

Scholarships available for BIPOC & marginalized groups