Intake for Pharmacologic Risk Triage

Pharmacologic Risk Triage (PRT) Intake*

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Receive a personalized, high-level risk assessment document that screens current medications, over-the-counter (OTC) products, and substances for any contraindicated or high-risk interactions or concerns with a planned psilocybin journey. This is an on-paper review only; no live meeting is offered with this consultation. This pharmacologic screening may be helpful to determine if a deeper Comprehensive Review & Pharmacologic Management (CRPM) consult could be beneficial (aka “triage”); however, it is not necessary to get a CRPM.

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 form 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. Your completed consult will typically be shared within 2 business days of this form submission. However, this turnaround time may be delayed depending on your response time to any needed clarifications.

As a reminder, this consult is completed by reviewing the information provided on this form; it does not offer a live meeting.
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:*
Date of birth:*

MonthDayYear
Name of Healing Center, Service Center or Facilitator where psilocybin will be consumed, if applicable*
if not applicable, state n/a
Email address for consult*
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).
Phone Number*
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
Psilocybin Use Context
Date of planned psilocybin journey/experience if known (approximate is ok):*
The following question is intended only to provide helpful context for this consult: In certain states with regulated access and licensed facilitators/centers, a medical provider may write a referral or give medical clearance for psilocybin in certain cases. Does the participant have medical clearance or a referral from a medical provider for psilocybin?*

N/AYesNoUnsure/Other (describe)
Where will/would the psilocybin be consumed? (Check any/all that apply)*
Consumed alone, or with a monitor/buddy/guide/facilitator?*

AloneWith a monitor/buddy/guide/facilitatorUnsure/Other (describe)
Will the participant be using regulated product?*
Participant Basic Health & Medication History
Height*
Weight*
Is the participant allergic to mushrooms?*

YesNoUnsure/Other (describe)
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 participant take as a SINGLE dose at once? 1 tabs, 3 tabs, 5mL, 30mg, 35 units?

Frequency = How often does the participant 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)

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

Reason for use = What is being prevented or treated with this med?
MEDICATION TABLE (Tip: use TAB to easily move through the fields. To move backwards: hold down SHIFT, then TAB as needed.)*
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 and/or result in less reliable information.

Most file types accepted. Limit 1 file.
Cancelof
Were any medications/OTCs started within the past 3 months? Approximately when started?*
If not applicable, state n/a
Are there any unlisted medications/OTCs that were discontinued within the past 3 months? Approximately when stopped?*
If not applicable, state n/a
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
Yes/No: Does the participant currently use nicotine (e.g., cigarettes, vape) on a daily or weekly basis?*
Yes/No: Does the participant currently consume caffeinated beverages on a daily or weekly basis?*
How often does the participant consume alcohol?*

1-2/dayWeekly basis but not dailyMonthly basis but not weeklyLess often than monthlyNever3+/day
List/describe any use of cannabis; or any use of substances that may not have been obtained through legal or medical channels. Please include frequency and reason for use.*
If not applicable, state n/a
Is the participant currently on hospice or palliative services?*
Payment

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

Pharmacologic Risk Triage (PRT) - includes up to 5 prescriptions + OTCs. Final cost depends on total number of prescriptions + OTCs.An individualized, high-level risk assessment that screens current medications, over-the-counter (OTC) products, and substances for contraindicated or high-risk interactions with a psilocybin journey.

$100.00 Total number of Prescriptions + OTC products

Total

$0.00

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Pharmacologic Risk Triage (PRT) Intake*

Authorized Representative Information (if applicable)

Participant Information

Psilocybin Use Context

Participant Basic Health & Medication History

Payment