Comprehensive Intake Form

Comprehensive Intake*

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Receive a complete pharmacologic evaluation and personalized medication management and safety plan in preparation for your psilocybin journey. For those who want careful guidance and more confidence. Includes a detailed written report plus a 30-minute live meeting. You may invite an attendee. Being on camera is not required.

Refer to the full description here.
"Participant" refers to the person receiving, or potentially receiving, psilocybin. This person could also be considered a "client" or a patient.

INSTRUCTIONS

Step 1: If you (participant) haven't already within the last 12 months, or you're not sure, please fill out this required Participant Communication, Consent and Release form. Then come back here!

Step 2: Fill out the below information. Ideally, this fill should be filled out by the participant or someone who knows the participant's medication profile and history very well.

Step 3: Soon after your submission, we may follow up with any needed intake clarifications to complete the review. Within 3 business days* of your submission, we will review all the information, draft initial recommendations, and share a link to schedule a 30-minute appointment to review and discuss the consult. Being on camera is NOT required. Additional attendees can be invited.

*Note this turnaround time may be delayed depending on your response time to any needed clarifications.

Formal documentation of the completed consult will be shared securely within 1-2 business days of the consultation appointment.
Current Date*

MonthDayYear
Date
Authorized Representative Information (if applicable)

Skip to participant section if you are the participant.
Relationship to participant (provider, therapist, facilitator, son, daughter, etc).
Authorized Representative Name

First NameLast NameSuffix
Preferred pronouns
Email
We may contact you at this email to clarify information or gather more details if necessary. However, the written consultation will only be shared to the email(s) specified on the participant's Communication, Consent & Release form.
Phone
We may contact you at this number to clarify information or gather more details if necessary.
Preferred form of contact if we need clarification or more details?

PhoneEmailEither
Participant Information

Please fill out this section as completely and accurately as possible to guide the best possible recommendations.
Name*

First NameLast Name
Pronouns
Sex assigned at birth:*
Email address*
We may contact the participant at this email to clarify information or gather more details if necessary. Additionally, the written consultation will be shared to this email (unless the participant opted out of receiving it on the Participant Communication, Consent & Release form).
Name of Healing Center, Service Center or Facilitator, if applicable*
if not applicable, state n/a
Phone Number*
We may contact you at this number to clarify information or gather more details if necessary.
Date of Birth:*

MonthDayYear
Date of birth:*
Preferred form of contact if we need clarification or more details?*

PhoneEmailEither
Psilocybin Use Context
What is the participant's current provider support surrounding natural medicine/psychedelic use (check ANY/ALL that apply)? This question is ONLY intended to understand the current level of support and to provide helpful context to complete the consult.*

Currently established with a psychotherapy provider who can provide therapeutic services around psilocybin use/therapyCurrently established with a prescriber who can make prescription changes if necessaryThe participant has medical clearance or provider referral for psilocybin use (only applicable in certain regulated states, and not always required in those states)None of the aboveOther
Is the plan for micro-dosing, or a macro-dose (journey)?*

Micro-doseMacro-dose (journey)Unsure
Date of planned psychedelic experience/journey, if known (approximate is ok):*
Goals of use (select all that apply):*

For healing or treatmentFor recreational use or consciousness explorationFor facilitator trainingFor spiritual/ritual use
Where will the psilocybin be consumed? (Check any/all that apply)*
Consumed alone, or with a monitor/buddy/guide/facilitator?*

AloneWith a monitor/buddy/guide/facilitatorOther/Describe
Consumed alone, or with a monitor/buddy/guide/facilitator?*
Describe any prior experience with psilocybin, whether microdosing or macro-dose (journey):*
State 'none' if none
If currently micro-dosing psilocybin, specify the mushroom strain if applicable/known, and the dosing regimen*
If not known or not applicable, state n/a
Will the participant be using regulated product?*
What form of psilocybin? (Check all that apply):*

Encapsulated ground material (e.g., ground mushrooms in capsules)Dried mushroomsFresh mushroomsTea or beverage prepared from ground dried mushroomEdibles (infused with a regulated amount of psilocybin)Extract (e.g., alcohol or water-based tinctures or concentrates)Sublingual or buccal formulation (e.g., lozenges or strips that dissolve in the mouth)UnsureOther/Describe
Will the psilocybin be administered in a group or just to the participant?*
Participant Health and Medication History
Height*
Weight*
Is the participant allergic to mushrooms?*

YesNo
Medication Allergies & Reactions (write 'none' if none)*
Medications and Over-the-counter (OTC) Products:

Enter participant meds and OTC products in the MEDICATION TABLE below the KEY. Remember to add items like aspirin and allergy meds. Remember to add items used infrequently or via other routes like injected, topical or inhaled.

Instead of filling out the table below, you may upload a full medication list under the table. However, in order to complete the assessment, the uploaded list will need to contain the information in the KEY below for each product. If incomplete information is provided in the upload, we may need to reach out for more information which will delay your consult and/or result in less reliable information.

KEY:

Rx/OTC Product Name = Enter the full prescription or over-the-counter (OTC) product name. For OTC products, be as specific and detailed as possible to allow us to look up the full ingredient list online if necessary. To save you time, you can enter a URL for the product page.

Form = How does it come? Oral tablet, topical ointment, injection, inhalation, etc.

Strength = Enter strength per unit, such as 5mg per capsule, 2mg/mL, 5%, 1mg-5mg/10mL. This could be a concentration. For OTCs with multiple ingredients (and strengths for each), simply put 'n/a'.

Dose = How much does the product or prescription directions say to take as a SINGLE dose at once? 1 tabs, 3 tabs, 5mL, 30mg, 35 units?

Frequency = How often does the product or prescription directions say to take the dose(s)? Once daily? 3 times daily? Once weekly? If the order is "as-needed" rather than a regular schedule, please specify that here (e.g., every 4 hours as needed)

As-needed frequency = If the medication is ordered "as needed", how many times per day or week does the participant end up taking it?

Route = How does the participant take it? By mouth? Inhaled? Intramuscular? Topical?

Reason for use = What is being prevented or treated with this med?

Duration = Specify if taking for years, months, weeks or days. If it is known how many years, months, weeks or days, please specify that.

Notes = Add any notes that you think might be helpful.
MEDICATION TABLE: Use TAB to move through the fields. TAB at the end to land on SAVE. Saving will add another row if you need it. To move backwards: hold down SHIFT, then TAB as needed.
Instead of filling out the medication table, you may upload a medication list with the full KEY information above. If incomplete information is provided in the upload, we may need to reach out for more information which will delay your consult.

Most file types accepted. Limit 1 file.
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Any medications/OTCs the participant takes differently from the product or prescription directions? Please explain.*
Check this box if there are more than 15 medications. If there are more than 15 medications, please email them to info@psychedelicinteraction.com with complete directions and reason for use (refer to the table below) at least 48h prior to our meeting. If you email the meds, please do NOT include the patient/participant name or other identifying information. Simply email the med list. Do not fill out the med table below, which only accepts up to 15 medications.
Medications & Supplements - enter all meds, even if just getting a deprescribing/tapering consult. Please include cannabis here if applicable. Remember to add items used infrequently or via other routes like injected, topical or inhaled. NOTE: press TAB to quickly move through cells & rows.
Were any medications/OTCs started within the past 3 months? If so, approximately when started?*
If not applicable, state n/a
Are there any unlisted medications/OTCs discontinued within the past 3 months? Approximately when stopped?*
If not applicable, state n/a
Describe any changes to dose or frequency of current medications within the past 4 weeks?*
If not applicable, state n/a
Have any of the participant's current medications/OTCs already BEEN IDENTIFIED for potential discontinuation or tapering (gradual reduction with goal to discontinue) in preparation for psilocybin?*
If not applicable, state n/a
Has the participant ALREADY TRIED tapering, reducing or stopping specific medications previously? Is the participant currently in the middle of any taper? Please provide details.*
If not known or not applicable, please state this.
If it's necessary to taper off a medication (slowly reducing doses over time until discontinued), sometimes success can take several months to a year--or some cases longer. What is the participant's preference?*

Willing to take as long as necessary for effectiveness and safety, even if it takes a year or longerWilling to take 6-9 monthsWilling to take 3-6 monthsWilling to take 1-3 monthsWilling to take a couple weeks
If looking to taper off more than 1 medication, is the participant willing to do one at a time? (There is typically more success and better tolerability with this approach.)*

N/AYes, and it's ok if each one takes as long as necessary for effectiveness and safety.Yes, as long as they can all be done within the time frame selected above.No, prefer to taper off all at the same time.
History of medication+psilocybin successes: List any medications the participant successfully tolerated (seemed to do fine with) during a prior psilocybin experience.*
If not applicable, state n/a
Has the participant successfully administered or taken your own pills or other medications during a journey without assistance in the past? Depending on your answer, we may need to determine plans to avoid the need to take medication during a journey (if appropriate), or ensure assistance is available to help administer medication(s).*
If not applicable, state n/a
Does the participant currently use tobacco or nicotine?*
What kind of tobacco or nicotine products? How often? How long been using?
How many servings of caffeine does the participant consume per day or week?*
If not applicable, state n/a
How often does the participant consume alcohol?*

Daily basisWeekly basisMonthly basis but not weeklyLess often than monthlyNever
If daily or weekly alcohol, how many servings per day or week?*
List/describe any use of cannabis; or any use of substances that may not have been obtained through legal or medical channels. If known, please include form, route, dose, frequency and reason for use. Regardless of legal status, these substances can also have important interactions and adverse effects to check for.*
If not applicable, state n/a
Describe any prior experience with psilocybin (indicate 'none' if none):*
Describe participant's exercise habits, if applicable:
Describe any special diet, if applicable:
Check the conditions that are current or past history:*

Acid Reflux or GERDAcute Coronary SyndromeADHDAlzheimer'sAnemiaAnorexiaAnxietyArrhythmia (abnormal heart rate or rhythm)Arthritis (osteoarthritis)AsthmaAtrial Fibrillation/flutterAutism spectrumAutoimmune Disorder, otherBenign Prostatic Hyperplasia (BPH)Bipolar 1 DisorderBipolar 2 DisorderBladder Control (overactive bladder)Bleeding or Clotting DisorderBlood disorder, otherBlindness or severe vision lossBrain InjuryBulimiaCancerCardiovascular disease, otherChest pain or anginaConstipation, chronicCOPDCystic FibrosisDepressive disorderDiabetes type 2Diabetes type 1Down's syndromeHearing Loss, severeHeadaches - migraine or clusterHepatitisHigh CholesterolHIV/AIDSKidney disease, severe or end-stageKidney function reducedLewy Body dementiaLiver disease, severe or end-stageLiver function reducedLung disease, otherLupusFall history or high fall riskFibromyalgiaFluid retention, swellingGlaucomaGoutHeart AttackHeart FailureHuntington's DiseaseHigh Blood PressuresHigh Heart Rates/PulseHyperthyroid or Grave's diseaseHypothyroid (low thyroid)Incontinence (urinary or fecal)Low Blood PressuresLow Heart Rates/PulseLung disease not on this listMacular degenerationManic symptomsMultiple SclerosisMotor or movement disorder, otherMyasthenia GravisNarcolepsyNeurologic condition, otherNerve PainObsessive Compulsive Disorder (OCD)Parkinson's DiseasePain - chronicPain - acutePeripheral Artery Disease (PAD)Personality DisorderPost-Traumatic Stress Disorder (PTSD)Psychosis (history of hallucinations, paranoia, delusions, others)Psychiatric condition, otherPulmonary Embolism (PE)Rheumatoid ArthritisSchizophrenia spectrumSciatic painSeizures or epilepsySickle Cell DiseaseSpinal stenosisSpinal Cord InjuryStrokeSubstance Use Disorder, AddictionSuicidalitySyncope or faintingTransient Ischemic Attack (TIA)Transplant recipientTremorUrinary RetentionVenous Thromboembolism (VTE)Weight loss, significant or suddenWeight gain, significant or sudden
Provide specifics about the condition(s) or list any important conditions not captured above:
Any family history of seizures, symptoms of psychosis, diagnosed bipolar disorder, schizophrenia, or psychosis spectrum condition? Briefly describe the family relationship and which condition(s) or symptoms.*
Is the participant still healing from any recent surgeries?*
If not applicable, state n/a
Does the participant have mobility difficulties or restrictions?*

NoneYes, but not using assistanceBed-boundWheelchairWalkerCaneCrutchesOther
Is the participant currently on hospice or palliative services?*
Does the patient/participant's blood pressures tend to be ABOVE 140/90 or BELOW 110/70?*
What is a typical blood pressure range for the participant?*
Does the patient/participant's heart rate (pulse) tend to be ABOVE 100 beats per minute or BELOW 60?*
What is a typical heart rate (pulse) range for the patient/participant?*
You may upload most recent lab/test results here, if available.

Most file types accepted. Limit 1 file.
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Does the participant have any known kidney disease or reduced kidney function? If known, provide the stage (number) or degree (mild/moderate/severe) of disease or impairment.*
If known/available, provide Serum Creatinine (SCr) or Creatinine Clearance (CrCl) or estimated Glomerular Filtration Rate (eGFR) and the date.
If known kidney disease or reduced kidney function, do you know the stage (number) or degree (mild/moderate/severe)?
Does the participant have any known liver disease or reduced liver function?*
If known liver disease, do you know the type of liver disease? Severity/stage (MELD, Child-Pugh score, mild/moderate/severe)?
Question, Request or Concern

By default, we will complete a personalized assessment and recommendations for medication management and safety planning around the journey. If you have an additional, specific question or request related to your consult, please specify that below.
If applicable, please provide a question or concern you'd like addressed during this consultation.
Payment

Process your payment securely via Stripe. Select the applicable options below. Please note if your prescription+OTC count differs from the selections below, we will adjust your final payment accordingly. Please note your credit card statement may say INTERACTION REPORT, INTERACTION CHECKER, or PHARMD CONSULT.*

Comprehensive Review and Pharmacologic Management (CRPM) - includes up to 5 prescriptions + OTCs. Final cost depends on prescriptions + OTCs.A full, deep pharmacologic evaluation and individualized medication management and safety plan in preparation for a psilocybin journey. For those who want careful guidance and peace of mind. Includes up to 5 medications/OTCs.

$200.00 Total number of Prescriptions + OTC products

Total

$0.00

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Comprehensive Intake*

Authorized Representative Information (if applicable)

Participant Information

Psilocybin Use Context

Participant Health and Medication History

Question, Request or Concern

Payment