🌳 Cannabis Meditation Intake

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Thank you for allowing me to join you on your journey! Find a quiet place to answer the following questions. Feel free to be as detailed as you’d like in your answers so that I can get to know you better and provide a safe and loving experience for you.

*All information will remain confidential.

Name *

Date of Birth

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Email Address

Phone Number

Emergency Contact Information
*

1. Current Physical Health:
Please describe your general physical health, any ongoing conditions, and how you are feeling currently.

2. Current or Past Medical Conditions:
Include any chronic illnesses, surgeries, or significant medical history.

3. Mental Health History:
Include any history of depression, anxiety, PTSD, bipolar disorder, schizophrenia, or other conditions.

4. Are you currently taking any medications/supplements?
Include dosage and reason for use.

5. Allergies or Dietary Restrictions:
Include food, environmental, or medication allergies.
*

Plant Medicine Experience

6. Have you used cannabis for medicinal, recreational, or spiritual purposes?
Describe your experience and frequency of usage.

7. What is your experience with psychedelics and/or plant medicine? Please provide details, including the types of plant medicines, frequency, and your experiences.
*

Intentions and Current Practices

9. What inspired or motivated you to work with this medicine?

10. What are your intentions for participating in this journey?
What do you hope to gain, explore, or release?

11. What aspects of your life would you like to work on and/or find more clarity?

Concerns and Support System

12. Do you have any specific concerns, fears, or hesitations about this journey?
Include physical, emotional, or logistical concerns.

13. Who is part of your current support system?

14. Do you have any current practices that support your mental, emotional, or physical health? Include practices such as meditation, breathwork, journaling, therapy, or other self-care routines.

Consent and Agreement

Please read the following statements carefully and check each box to indicate your agreement:

I confirm that I have disclosed all relevant medical and mental health information to the best of my knowledge.

I understand that this journey may involve physical, emotional, and spiritual experiences, and I take full responsibility for my participation.

I understand that Cannabis is a psychoactive substance and its effects vary from person to person

I consent to participate in this journey and release the facilitator(s) from any liability related to my participation.

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