Spirit Pharmacist Consultation Intake Form

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Name* This field is required.
First Name
Middle Name
Last Name
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E-mail* This field is required.You must supply a working email address for consultation service
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Mailing List Sign UpIf you check the box below, the email address supplied will be added to Spirit Pharmacists' mailing list
Yes, sign me up!
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Preferred Contact Method for Consultation* This field is required.Please use the following to select a contact method. International consultation will take place via Zoom.
Phone
Zoom
Signal App
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Contact NumberPlease complete with phone number including area code
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Age* This field is required.
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Gender
Male
Female
Other
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Height (inches)
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Weight (pounds)
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Have you ever been diagnosed or suspect you have any of the following medical conditions?* This field is required.Please select all that apply and describe further in the next page of the form
High blood pressure
Heart attack
Heart arrhythmia
Stroke
Heart failure
Coronary artery disease
Chest pain or angina
Epilepsy or seizure disorder
Current Pregnant or Breastfeeding
Liver or kidney failure
Cancer
Diabetes
Asthma or COPD
Traumatic Brain Injury
None of the above
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Do you have any other medical conditions?* This field is required.
YESNO
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Description of medical condition(s)Please use this space to FURTHER DESCRIBE medical conditions from the previous page. Information on how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc. is welcome.
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Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?* This field is required.Please select all that apply and describe further below. f you do not have any of the psychiatric conditions listed please select 'none of the above'.
Depression
Anxiety
Post Traumatic Stress Disorder (PTSD)
Substance Use Disorder or Addiction
Obsessive Compulsive Disorder (OCD)
Schizophrenia or other psychotic condition
Bipolar disorder
Personality disorder
None of the above
Other
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Description of psychiatric condition(s)Pleas use this space to describe any psychiatric condition you have further here
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Have you ever been hospitalized for a psychiatric reason?* This field is required.If yes please describe further below
YESNO
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Description of psychiatric hospitalization(s)
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Do you have suicidal thoughts or have you made a suicide attempt?* This field is required.If yes please describe further below
YESNO
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Description of suicidal thoughts or attempt
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Do you currently use any prescription medication?* This field is required.
YESNO
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Prescription medicationsPlease include a complete list of your prescription medications including the drug NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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Do you currently take or use any over the counter (OTC) medications, supplements, or herbal products?* This field is required.
YESNO
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OTC medication, supplements, and herbal productsPlease include a complete list of your OTC medication, supplements, and herbal products including the NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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Do you use alcohol?* This field is required.
YESNO
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How often do you use alcoholPlease select the option that most closely matches your use
1 drink per month or less
1 drink per week or less
A few drinks per week
A few drinks most days
Several drinks most days
Several drinks every day
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Further Description of Alcohol Use
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Do you smoke or use tobacco products?* This field is required.
YESNO
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Further description of tobacco useWhat kind of tobacco product to you use? how often? for how long?
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Have you used any of the following substances in the past 3 months?* This field is required.If you have not used any please mark 'none of the above'
Cocaine
Methamphetamine
Heroin or non-prescription opioids
Inhaled nitrates
GHB
Cannabis
None of the above
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Further description of substances used:How much of each substance? How often? Any additional commentary you wish to offer.
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Have you used psychedelics previously?* This field is required.Psilocybin mushrooms, LSD, ayahuasca, DMT, MDMA, ketamine, ibogaine, mescaline etc.
YESNO
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Description of Past Psychedelic UsePlease describe the use and experiences with previous psychedelics.
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Planned PsychedelicsPlease list psychedelics you may be interested in using or are hoping to learn more information about
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Questions or topics for discussion* This field is required.Please use this space to type any specific questions you may have either about your medications or psychedelics as well as what you're hoping to gain from your consultation most
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Please review the terms and conditions of consultation prior to form submission* This field is required.
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How did you hear about Spirit Pharmacist?
Internet search engine
Referral
Social media
Podcast or other media
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Who referred you?
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Please verify that you are human* This field is required.
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