Mindful Microdosing Intake Form

Let’s work together! All information is confidential.

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Payment Info: Venmo @Lauren-Alderfer

Other Options: Paypal, Interac, Zelle, and Square

Basic Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Meeting Preference

Emergency Contact

First Name

Last Name

Phone

(###)

###

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Background Information

Introduction

Please tell me a little bit about yourself

What brings you here today?

What are your hopes for your microdosing exeperience?

Your Experience

Have you ever microdosed or used psychedelics? If so, please describe.

Health Information

Overall Health

Excellent

Good

Fair

Poor

Have you ever had any of the following

Check All That Apply

Tinnitus

Color Blindness

Epilepsy

Valvular Heart Disease (VHD)

Medication

Do you take any antidepressants or SSRI medication? If so, please provide details.

Sensitivity / Allergy

Do you have any sensitivities to plant or allopathic medicine? Food or other allergies? Please provide details.

Prescriptions

Current prescription or over-the-counter medications

Mental Health

Have you been diagnosed or self-diagnosed with any mental health conditions? Please provide details.

Sleep

Please explain the quality of your sleep and the use of any sleep aids.

Health Survey

Select a number between 1 - 10 to share your level of concern in the following areas.

Personal Relationships

Depression

Headaches

Physical Health

Mood Swings

Sleep Issues

Memory

Physical Pain

Mental and Emotional Health

Anger Issues

Fatigue/Lethargy

Anxiety

Panic/Anxiety Attacks

Hormonal Issues

Eating Issues

Allergies

Emotional Trauma/PTSD

Did I miss anything?

Is there anything else you would like to share or do you have specific questions for me?

Digital Signature

By typing your name you are indicating that the information you entered above is accurate. I understand that I am receiving information for educational purposes and it is not to be misconstrued as medical or legal advice. I understand that I am not receiving medical services or diagnosis. This provider is not supplying psychoactive or controlled substances and I understand that I am solely responsible for my decisions and actions. Payment to be made after review of intake form prior to session. Preferred payment: Venmo @Lauren-Alderfer Other Options: Paypal, Interac, Zelle, and Square