Psychedelic Journey QUESTIONNAIRE

Retreat

This is the first step in the process.

Please complete and return before we are able to schedule a Pre-Journey Intention Call. It is at that time that we will review this form together.

Answer this questionnaire as thoroughly as possible. It is very important that we are aware of any medical conditions, medications, supplements, life experiences or habits that can

influence your experience. It is our intention for you to have the most amazing and safest experience possible. This is a confidential record.

Step 1 of 11

Name

This field is for validation purposes and should be left unchanged.

Full Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Best Phone Contact (cell)(Required)

Email(Required)

Date of Birth(Required)

Month

Day

Year

Gender

Referred by:(Required)

How did you hear about me or my Company?

PSYCHEDELIC EXPERIENCE

Are you experienced with psychedelics?(Required)

Yes

If so, describe the substance(s), dose(s), set(s) and setting(s). Was it in a recreational or ceremonial context?

Please describe, in detail, the types of substance taken, when, how much (if known), and the situation or purpose of taking the substance.

What influence have these experiences had on your life?

Have you had any challenging or problematic experiences?

IF you have had any problematic experiences, please describe, in detail, the type of substance taken, when, how much (if known), and the situation.

What insights have you had during psychedelic experiences

What types of difficulties have you worked through during psychedelic experiences?

What are your concerns/attitudes about engaging in psychedelic experiences? Please describe any concerns.(Required)

What do you wish to gain from this experience? What are your intentions in pursuing this work?(Required)

MENTAL HEALTH HISTORY

If you have the symptoms below, please note the number rating that best describes their severity. If you don’t have symptoms, leave blank. 1 = mild/sometimes 2 = moderate/often 3 = severe/constant

Anxiety

Hopeless outlook

Poor memory

Depression

Lonely

Dislike criticism

Bad temper

Easily stressed

Nervousness

Do you have any current or past psychological or psychiatric conditions?(Required)

Yes

Please give the dates and describe the circumstances.

Do you currently see a psychiatrist, psychologist or counselor?(Required)

Yes

How often?

Have you ever been hospitalized for a psychiatric condition?(Required)

Yes

Please give the dates and describe the circumstances.

Have you ever been abused? Was the abuse physical, mental, emotional, sexual?(Required)

Have you experienced trauma?(Required)

Yes

Please give the dates and describe the circumstances.

Have you ever been suicidal?(Required)

Yes

Please give the dates and describe the circumstances.

SUBSTANCE USE HISTORY

How often do you use alcohol, drugs, or any consciousness-altering substances? Please describe your use of any substances throughout your life, and those you have used in the past three months.(Required)

Have you had any adverse reactions to alcohol, drugs, or any consciousness-altering substances? Please describe in detail the type of substance taken, when, how much (if known), the situation or purpose of taking the substance, and the adverse reaction.(Required)

Are you sensitive or tolerant to any substances? Have you had to take more or less of a substance than usual to experience an effect? If so, please describe.(Required)

Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe.(Required)

DETAILED MEDICAL HISTORY

Considering your age, how would you describe your overall health?(Required)

Excellent

Good

Fair

Poor

In general, how satisfied are you with your life?(Required)

Very satisfied

Mostly satisfied

Somewhat disappointed

Mostly disappointed

Do you have any medical conditions? If so, are you currently in the care of a health-care professional? Please describe the conditions and current treatment.

Are you pregnant?(Required)

Yes

Do you have a history or present condition of high or low blood pressure?(Required)

Yes

Do you have any history of iron deficiency anemia?(Required)

Yes

When and where are you being treated for iron deficiency anemia?

Last Complete Physical Exam: Month & Year(Required)

Last Blood Test: Month & Year(Required)

Any abnormal findings?

For the following, please describe event and list date of occurrence:

A. Surgeries

B. Major Accidents

C. Hospitalizations

PERSONAL AND FAMILY HISTORY

Do you have or had any of the follow:

Allergies(Required)

Yes

Past

Anemia(Required)

Yes

Past

Anxiety(Required)

Yes

Past

Asthma(Required)

Yes

Past

Auto-Immune Disease(Required)

Yes

Past

Bipolar Disorder(Required)

Yes

Past

Cancer(Required)

Yes

Past

Depression(Required)

Yes

Past

Diabetes(Required)

Yes

Past

Heart Attack(Required)

Yes

Past

Heart Disease(Required)

Yes

Past

Headaches/migraines(Required)

Yes

Past

High Blood Pressure(Required)

Yes

Past

Liver Disease(Required)

Yes

Past

Osteoporosis(Required)

Yes

Past

Psychosis(Required)

Yes

Past

Schizophrenia(Required)

Yes

Past

Stroke(Required)

Yes

Past

Thyroid Disease(Required)

Yes

Past

Does your family have or had any history of the follow:

Allergies

Father

Mother

Grandparents

Siblings

Anemia

Father

Mother

Grandparents

Siblings

Anxiety

Father

Mother

Grandparents

Siblings

Asthma

Father

Mother

Grandparents

Siblings

Auto-Immune Disease

Father

Mother

Grandparents

Siblings

Bipolar Disorder

Father

Mother

Grandparents

Siblings

Cancer

Father

Mother

Grandparents

Siblings

Depression

Father

Mother

Grandparents

Siblings

Diabetes

Father

Mother

Grandparents

Siblings

Heart Attack

Father

Mother

Grandparents

Siblings

Heart Disease

Father

Mother

Grandparents

Siblings

Headaches/migraines

Father

Mother

Grandparents

Siblings

High Blood Pressure

Father

Mother

Grandparents

Siblings

Liver Disease

Father

Mother

Grandparents

Siblings

Osteoporosis

Father

Mother

Grandparents

Siblings

Psychosis

Father

Mother

Grandparents

Siblings

Schizophrenia

Father

Mother

Grandparents

Siblings

Stroke

Father

Mother

Grandparents

Siblings

Thyroid Disease

Father

Mother

Grandparents

Siblings

Do you/have you taken any of the following medications regularly?

Antacids(Required)

Yes

Past

Antibiotics(Required)

Yes

Past

Antidepressants(Required)

Yes

Past

Anti-anxiety meds(Required)

Yes

Past

Asthma meds(Required)

Yes

Past

Blood Pressure meds(Required)

Yes

Past

HIV meds(Required)

Yes

Past

Laxatives(Required)

Yes

Past

MAOI's(Required)

Yes

Past

Pain relievers(Required)

Yes

Past

Sedatives(Required)

Yes

Past

Sleeping Pills(Required)

Yes

Past

Stimulants(Required)

Yes

Past

Steroids(Required)

Yes

Past

What Medications are you currently taking? (It is essential that we know ALL prescription and over the counter meds) Medication Dosage for what? For how long?(Required)

Are you more or less sensitive to any medications? (Have you had to take more or less of a medication to experience the desired effects?)(Required)

Have you had any adverse reactions to these medications? Have you experienced or are you currently experiencing any side effects from these medications? If so, please describe:(Required)

Do you/have you taken any of the following supplements regularly?(Required)

Yes

Past

B Vitamins(Required)

Yes

Past

5-HTP(Required)

Yes

Past

L-Tryptophan(Required)

Yes

Past

Melatonin(Required)

Yes

Past

SAM-e(Required)

Yes

Past

GABA(Required)

Yes

Past

L-Tyrosine(Required)

Yes

Past

Guarana(Required)

Yes

Past

Licorice(Required)

Yes

Past

St. John's Wort(Required)

Yes

Past

Please list any other supplements you are taking. Be sure to include any vitamins, minerals, herbs, homeopathics, and other health aids. (It is essential that we know ALL supplements)(Required)

Supplement Dosage ? For What? For how long?(Required)

Have you had any adverse reactions or side effects from any of these supplements? If so, please describe:(Required)

ALLERGIES/SENSITIVITIES

Check all that apply:

Antibiotics

Alcohol

Aspirin

Citrus

Codeine or morphine

Dairy

Dust

Fumes

Grass

Molds

Penicillin

Pets

Pollen

Smoke

Mean People

Trees

Weeds

Wheat

Other

DIET AND DIGESTION

A. Are there any diet restrictions or regimens that you follow? If yes, please describe:(Required)

B. How much water do you drink per day (litres)?(Required)

C. Do you consume grapefruit or grapefruit juice regularly?If so, how much and how often?(Required)

EXERCISE

A. I exercise _________ days/week(Required)

B. Are you satisfied with your level of fitness?(Required)

Yes

C. What physical activities do you enjoy doing or are interested in?(Required)

SLEEP

A. How many hours of sleep do you usually get a night?(Required)

B. Any trouble falling or staying asleep? Please Describe:(Required)

C. Do you wake feeling refreshed?(Required)

Always

Usually

Rarely

Never

PERSONAL HABITS

Please indicate if you use any of the following

Tobacco

Caffeine

Alcohol

Soda

Number of cigarettes per day

Number of cups of caffeinated drinks per day

Number of alcoholic drinks per week

Number of ounces of soda per day

INTEGRATION

This work may lead to profound shifts in your life and it is ideal to have a framework of resources in place ahead of time to support you before, during and after sessions. Having support to help you integrate the experience can help you to get the most benefit from the work.

A. What friend(s), loved one, counselor or other trusted person(s) do you speak with about this work?(Required)

B. What are their attitudes towards you in pursuing this work?(Required)

C. What practices do you feel will be most beneficial in helping you to integrate this experience into your life? (ie. speaking with trusted persons, art, bodywork, journaling, time in nature, etc) How will you put them to use?(Required)

D. Is there anything else you would like us to be aware of or any specific questions you have?(Required)

EMERGENCY CONTACT

In the event of an emergency who should we contact?

Name(Required)

First Last

Relation:(Required)

Phone(Required)

Country Phone Number

Have you made them aware that you are planning to undergo this treatment?(Required)

Yes

Name

First Last

Relation:

Phone

Country Phone Number

Have you made them aware that you are planning to undergo this treatment?

Yes

Please read and sign:(Required)

I understand that accurate reporting of the above information is necessary to help ensure
that I have a safe and beneficial experience. I realize that failure to provide accurate
information may compromise my experience. I have answered this questionnaire
truthfully to the best of my ability.

I am responsible for my health and I understand that my participation in this event may pose some risks. To the best of my knowledge, I am in good physical condition and I am not aware of any physical or psychological infirmity, which would place me at risk to participate in any way.

In the event of a medical emergency, I agree to seek emergency medical care and give permission to initiate contact with emergency medical providers. I will utilize appropriate support so that I may optimize the benefit of this experience, and reduce any risks.

In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE,
DISCHARGE AND COVENANT NOT TO SUE the Guide(s), Sitter(s) and participants from any and all liability, claims, demands, or course of action whatsoever arising out of, or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property
belonging to me whether caused by the negligence of release, or otherwise, while
participating in this event, or while in, on or upon the premises where the event is being
conducted.

I agree to indemnify and hold harmless those with whom I engage this work.

I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS,
PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be
sustained by me, or any loss or damage to property owned by me as a result of being
engaged in the event’s activities whether caused by the negligence of release, or otherwise.

In signing this release, I acknowledge and represent that I have read, understood and signed
the form voluntarily; I am an adult, of at least nineteen years of age or older, and fully
competent; and I execute this Release for full, adequate and complete considerations fully
intending to be bound by same.

This waiver applies to all present and future work with this Guide, Leader/Organization.

In signing this release, I acknowledge and represent that I have read, understood and signed the form voluntarily; I am an adult, of at least nineteen years of age or older, and fully competent; and I execute this Release for full, adequate and complete considerations fully intending to be bound by same.

Signature(Required)

Your Name
Your Name
Your Name

Need Help?

Email support@becometriggerproof.com

You just took a big step. We can't wait to help you get clarity and show you the path forward.

See you soon.

— THE TRIGGER PROOF™ TEAM

Psychedelic Journey QUESTIONNAIRE

Retreat

This is the first step in the process.

PSYCHEDELIC EXPERIENCE

MENTAL HEALTH HISTORY

SUBSTANCE USE HISTORY

DETAILED MEDICAL HISTORY

PERSONAL AND FAMILY HISTORY

DIET AND DIGESTION

EXERCISE

SLEEP

PERSONAL HABITS

INTEGRATION

EMERGENCY CONTACT

Need Help?

You just took a big step. We can't wait to help you get clarity and show you the path forward.

MENU