About this template
This Psychedelic Experience Intake Form is designed for practitioners, guides, and mental health professionals preparing clients for psychedelic-assisted sessions or integration work. Gathering a comprehensive history—including medical background, psychiatric history, current medications, substance use, and personal intentions—is critical for ensuring client safety, managing contraindications, and tailoring the session to individual needs.
Doc2Form allows you to instantly transform this structured questionnaire into a ready-to-use Google Form. Collect detailed disclosures securely and review responses effortlessly within your standard Google Workspace environment. The template covers physical metrics, medical conditions, past substance experiences, current life stressors, and specific intentions for the journey, providing a thorough baseline for any therapeutic or preparatory protocol.
Using a digital intake form streamlines client onboarding, reduces administrative friction, and ensures that sensitive disclosures are documented accurately before consultations begin.
Key features
- Collect thorough medical and psychiatric history securely
- Screen for contraindications and prescription medications
- Assess past substance and psychedelic use history
- Understand client intentions, goals, and desired outcomes
- Gather emergency contact and consent details in one step
Use cases
- Psychedelic therapy and integration practices
- Ketamine-assisted psychotherapy intake
- Holotropic breathwork and ceremonial preparation
- Clinical research studies on psychoactive substances
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Email Address (Short answer)We will use this to send you session materials and prep instructions.
- Phone Number (Short answer)Include your country and area code.
- Age (Short answer)Enter your current age in years.
- Gender Identity (Dropdown)Select the option that best describes how you identify.
- Height and Weight (Short answer)Please provide your height (in inches) and weight (in pounds) for safety dosage calculations if applicable.
- Known Allergies (Paragraph)List any allergies to medications, foods, or environmental triggers.
- Active Medical Conditions (Checkboxes)Select any conditions that apply to your current health status.
- Medical Condition Details (Paragraph)Provide additional context for any medical conditions selected above.
- Current Prescription Medications (Paragraph)List all prescription medications you currently take, including dosages.
- Over-the-Counter Medications & Supplements (Paragraph)List any regular supplements, vitamins, or OTC drugs you use.
- Relevant Medical Records (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe any relevant medical documents you wish to share.
- Psychiatric Conditions (Checkboxes)Select any conditions you have been diagnosed with or treated for.
- Psychiatric Hospitalization History (Paragraph)Have you ever been hospitalized for psychiatric reasons? If yes, please provide approximate dates and context.
- History of Suicidal Ideation (Paragraph)Have you experienced suicidal thoughts or attempts in the past? Please share relevant context if comfortable.
- Alcohol Use Frequency (Dropdown)How often do you consume alcoholic beverages?
- Substances Used in the Past 3 Months (Checkboxes)Select all substances used recently.
- Past Psychedelic Use Details (Paragraph)Briefly describe any prior experiences with psychedelics, including approximate dates and substances.
- Primary Intention (Paragraph)What is your main intention or question for engaging in this psychedelic experience?
- Desired Outcomes (Paragraph)What shifts, insights, or resolutions are you hoping to achieve?
- Current Major Stressors (Paragraph)Describe any current life stresses, transitions, or challenges you are facing.
- Support Network (Checkboxes)Who forms your current support system? Select all that apply.
- Terms and Confidentiality Agreement (Multiple choice)Please confirm that the information provided is accurate and that you understand the scope of the services offered.
FAQ
How do I share this form with my clients?
Once Doc2Form generates your Google Form, you can easily share the link via email, embed it on your private practice website, or send it as part of your automated onboarding workflow.
Can I customize the medical and psychiatric screening questions?
Yes! Because the template lives in your Google Drive as a standard Google Form, you can add, remove, or edit any questions to match your exact clinical protocols.
Is this form template secure and private?
The form is hosted securely in your organization's Google Drive account, allowing you to maintain full control over client data and privacy compliance.
How do clients upload relevant medical records or files?
Since Google Forms handles file sharing via links, the form includes dedicated text fields where clients can securely paste links to documents stored in Google Drive or other cloud services.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.