Name *

Email Address *

Phone Number *

Birthday or Age *

City and State of Residence *

Emergency Contact: Name, Relationship, Phone and/or Email

How did you hear about Paul Antico/Panimus Integration?

Which offering are you most interested in? Choose only one, we can discuss others when we connect. Which offering are you most interested in? Choose only one, we can discuss others when we connect. Compassionate Inquiry sessions Rosen Method Bodywork sessions Psychedelics: Integration, Journeys, Preparation Safe and Sound Protocol (SSP) Microdosing Consultation

Level of Education Completed Level of Education Completed High School / GED Some College / Associates Degree College Degree Advanced / Graduate Degree Trade Tech Degree or Cert of Completion N/A

Relationship status Relationship status Committed Relationship Married Single Polyamorous Other

Occupation

What are your Integration Interests? What are your Integration Interests? Pre-Journey Guidance and Preparation Trauma Informed, Somatic Approach, Journey Guidance Post-journey Guidance and Integration Medicine Choices Appropriate Dosage Considerations Other (please describe below in the "additional" section)

Purpose and Intention: What are your goals, hopes, expectations for this work? What are you seeking? *

Purpose and Intention: What are your concerns or fears regarding this work, if any? *

Please list any psychological, psychiatric, and/or other mental health issues (Ex. anxiety, depression, ADHD, PTSD, personality disorder, addictions, etc.) and if they have been formally diagnosed or not. *

Have you ever been suicidal or attempted suicide? If yes, please provide details. *

What is your sexual orientation, expression, and preferred pronouns? Have you had sexual trauma? *

Have you been subject to oppression, racial trauma, ancestral (family history) trauma? *

Please list all prescribed medications. Indicate which are currently being used and which had been previously used (ex: Adderall, Zoloft, etc.) *

Do you currently have any medical conditions? How would you describe your health? *

Recreational Substances: Please list all recreational substances currently using (ex: alcohol, tobacco, cannabis, cocaine, etc.) Include the frequency of use (times per day/week/month and for how long of a duration you have been using: months/years) *

What is your experience with plant medicines or other psychedelics? (Ex: Ayahuasca, cannabis, Peyote, LSD, 5-MeO-DMT, San Pedro, Salvia, MDMA, Ketamine, etc.) For each, please include a rough estimate of times used, setting in which taken (therapeutic, recreational, ceremonial, etc.), and any perceived risks/harms/difficulties and benefits/gains identified. *

Self-development/resources: Please describe your current spiritual and/or self-development, self-care, and wellness practices (Ex: meditation, journaling, yoga, prayer, breath-work, etc.). *

Self-development/resources: Do you currently have a therapist or other counselor (Ex. Psychologist. Psychiatrist, Coach, etc) that can support you in this work? *

Self-development/resources: Do you have a partner, friends, or others you can reach out to for support during this work? *

Self-development/resources: Are you part of a supportive community? *

Limitations: Do you have any physical conditions that limit your mobility or compromise your health? *

Please check the box if the statement was TRUE for you before your 18th birthday. Total your checkboxes in the next question. Please check the box if the statement was TRUE for you before your 18th birthday. Total your checkboxes in the next question. Did a parent or other adult in the household often or very often: Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? …..*****….. Did a parent or other adult in the household often or very often: Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? …..*****….. Did a parent or person at least 5 years older than you ever: Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? …..*****….. Did you often or very often feel that: No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? …..*****….. Did you often or very often feel that: You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? …..*****….. Were your parents ever separated or divorced? …..*****….. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit longer than at least a few minutes or threatened with a gun or knife? …..*****….. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? …..*****….. Was a household member depressed or mentally ill, or did a household member attempt suicide? …..*****….. Did a household member go to prison? …..*****…..

How many checkboxes did you select in the previous question? How many checkboxes did you select in the previous question?012345678910

Additional: Is there anything else you think we should know or that you would like to share with us before taking the next steps in this process?

Thanks for your interest in Stephan Porges (Polyvagal Theory) Safe and Sound Protocol. We will send information and contact you. The SSP has its own APP and intake form.