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? *

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.