Pre-Session Questionnaire

1

Personal Information

Full name *

Today's date *

Date of birth

Age

Height

Weight

Cell phone

Email address *

Emergency contact — name & phone number

How did you hear about us?

Educational background

Occupation (last 10 years)

Current spouse/partner name & length of relationship

Children — names & ages

Religious or spiritual affiliations, if any

2

Personal Practices

Describe your current exercise regimen

Describe your current meditation practice

Describe what the first 3 hours of your average day look like

Describe what the last 3 hours of your average day look like

3

Life Balance

Rate how balanced each area feels in your life right now — 1 being unbalanced, 10 being fully balanced.

Primary partnership5

Physical5

Spiritual5

Family5

Career5

Personal relaxation5

Social5

Play5

1 — Unbalanced10 — Balanced

✦

Rank the above eight areas in order of priority to you right now — 1 being most important.

1st

2nd

3rd

4th

5th

6th

7th

8th

What is going well in your life right now?

What is not so great in your life right now?

How would you describe your overall satisfaction with life right now?

How committed are you to changing the areas of your life that are not satisfying?

Commitment level5

1 — Not committed10 — Very committed

Share your thoughts about your commitment level

Describe your current top two challenges in each area:

Emotional

Professional

Spiritual

Physical

Describe three primary outcomes you would like from your session:

Outcome 1

Outcome 2

Outcome 3

4

Medical History

It is essential that we have complete and accurate medical history. Please take your time in this section and do not leave anything out.

Medical conditions treated in the last 5 years — include details and approximate dates

Are you currently taking any prescription medications?

NoYes

List each medication — name, dosage, and frequency

Have you taken any prescription medications in the past 6 months that you are no longer taking?

NoYes

List each medication — name, dosage, frequency, and reason for stopping

Have you ever been treated for any psychiatric condition?

NoYes

Describe each condition, medications prescribed, and dosages

Please describe any checked items in detail with approximate dates

5

Substance Profile

Do you consume alcohol?

NoYes

What type and approximately how much per week?

Do you use any tobacco products?

NoYes

What type and approximately how much per week?

Have you ever attended an alcohol or substance treatment program?

NoYes

Please describe and provide approximate dates

Non-psychedelic substances used in the last 5 years — include frequency and last time used

Psychedelic substances and/or plant medicines used in your lifetime — include number of instances, last time used, and any notable experiences

6

Transpersonal Experiences

Have you ever had an out-of-body experience that you could not control?

NoYes

Describe in detail

Have you ever experienced an overwhelming or uncontrollable surge of energy moving through your body or mind?

NoYes

Describe in detail

Have you ever tried to channel or directly connect with information or entities outside of yourself?

NoYes

Describe in detail

Have you ever had a prolonged experience of feeling disconnected from or outside of your own body?

NoYes

Describe in detail

Have you ever — in a normal waking state — felt as if you were walking through a dream?

NoYes

Describe in detail

How open are you to experiencing ancient ceremonial and/or spiritual practices outside traditional Western norms?

Openness5

1 — Not open5 — Curious10 — Very open

What best describes your reason for choosing this type of session? Select all that apply.

Do you have any concerns that this type of session could be detrimental to you?

NoYes

Please share your concerns openly

Anything else you feel is important for us to know?