Medicine Journey Intake Form

The information you provide is confidential and will not be shared.

First and Last Name

Phone

Town, State

Why are you interested in a Medicine Journey?

Have you done a Medicine Journey before? If so, please provide some basic details such as where, when, and under what circumstances. (We don’t need specific dates or names - just a general idea of your previous experience.)

What is your intention for your Medicine Journey?

Are you taking any prescribed medications for any reason? If so, which ones?

Have you ever been diagnosed with a mental illness? If so, what was the diagnosis? What have you done about it so far?

Have you ever been prescribed any SSRI medications for depression or other mental health issues? Are you currently taking any SSRI medications?

Have you recently, or are you currently, undergoing significant trauma or stress in your life? If so, please provide more details including how you are responding.

Are you aware of any addictions or addictive behaviors that you have? If so, please provide more details including how you are responding.

What questions or concerns do you have about this Medicine Journey?

Are you interested in a two -night retreat Journey, or a day Journey (only available if you are within a 45 minute drive), What dates are you interested in for your Medicine Journey?

Thank you for completing our intake form.