Spiral Web Deep Meditation Intake
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Full Name *
Email
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Date of Birth
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Phone Number
Pronouns
Please share any identities that feel meaningful to you i.e queer,  non-binary,  BIPOC, parent, etc.
How did you learn about us?
What brings you to be interested in participating in a deep meditation at this time? Is there something specific, such as a particular event? Please be as detailed as you can.
What do you hope to gain from this experience?
Please share any medical condition or health concerns you are coping with. *
Specify all medications and supplements you are presently taking and for what reason. *
Do you have an allergies to foods, medication, or other?
If taking prescription medication, who is your prescribing provider? Please include the provider's name and phone number. (I would only contact your provider with your written consent)
Who is your primary care provider? Please include, name and phone number. (I would only contact your provider with your written consent)
Please share any current or recent mental health diagnoses, challenges, or concerns you may have? (please describe)
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Have you ever had suicidal thoughts? How long ago? Content/nature of the thoughts? (specific plan? Wish to escape or not exist?)
Have you had suicidal thoughts in the last two weeks?
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Have you ever attempted suicide?
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If "yes" or "maybe" to having attempted suicide, how long ago?
Do you have thoughts or urges to harm others?
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If "yes" or "maybe" to the above, have you acted on those thoughts? Please describe:
Do you drink alcohol? If so, frequency and amount.
Do you use any kind of substance, drug or plant medicine? Please specify types and general usage patterns.
Have you ever been hospitalized for a psychiatric issue? If so, please provide general details and date(s)

Are you currently receiving support from another counselor, coach or other caring professional?

Please share any known history of mental illness in your family? Please provide who and what you know about their diagnosis/diagnoses.
If you are in a relationship, please describe the nature of the relationship and months or years together
Describe your current living situation. Do you live alone, with others? with family, etc.
What is your current occupation? What do you do? How long have you been doing it?
Do you have any access needs or preferences that haven't been asked about or discussed? Please describe:
Do you have prior experience with deep meditation, non-ordinary states of consciousness, psychedelic journeys or spiritual or plant medicine ceremonies? If so, please briefly describe: *
Please describe any other recreational or other experiences with plant medicines, psychedelics, or non-ordinary states of consciousness?
What is your interested in participating in this type of event at this time? Is there something specific? *
Do you have any concerns going into this experience? Please describe:
What do you hope to gain from this experience? *
What else would you like us to know?
Please provide an Emergency Contact of someone who knows the kind of deep meditation practice you'll be engaging with. Include 1. Name, 2. Relationship, and 3. Phone Number *
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