Name *

Email Address *

Phone Number *

Birthday *

City and State of Residence *

Occupation

Level of Education Completed

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? *

Relationship status * Relationship status * Committed Relationship Married Single Polyamorous Other

How is your sleep? Do you get a good night’s sleep? Do you have issues falling asleep or staying asleep? *

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, etc.) Include the frequency of use (times per day/week/month and for how long of a duration you have been using: months/years) *

Have you ever taken plant medicines or other psychedelics? If so, what was your experience? (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.). *

Do you exercise? If so, what do you do for exercise? *

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? *

Diet and Nutrition: Please describe your current diet, herbal supplements and any special restrictions (Ex: vegan, diabetic, etc.)

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?

[PSIP] How did you hear about Paul Antico/Panimus Integration?