Have an account?

Assessment Form

Thank you for completing this Health Intake form.

This information is essential to support your safety and well-being throughout our work together. Your responses help us assess any medical or psychological considerations that may impact your participation.

This form is required and will be reviewed only by jonikim L.L.C. Your information is kept strictly confidential and stored securely.

We ask that you answer every question honestly and thoroughly. Please do not withhold any information you believe may be relevant — even if you’re unsure whether it matters. Your openness allows us to create the safest and most supportive experience possible.

We appreciate your trust and will reach out directly if anything needs clarification.

Section 1: Personal

First name*

Last name*

Email Address*

please be sure to use the same email address for all forms and correspondence

Phone Number

Date of Birth

Month

Day

Year

Emergency Information

Full Name

Phone Number

Relationship

Section 2: Medical Conditions & Physical Health

1. Do you have or have you ever had any of the following physical health conditions? (click all that apply)*

Diabetes

High blood pressure

Cardiovascular disease

Cardiac issues (e.g., arrhythmia, heart attack)

Liver impairment

Seizure disorder or epilepsy

Stroke

Traumatic brain injury or other significant head trauma

Asthma or other respiratory condition

Chronic pain or mobility limitations

Bladder issues (e.g., ulcerative cystitis)

Immunocompromised condition (e.g., cancer treatment, HIV, autoimmune)

Currently pregnant, breastfeeding or trying to conceive

Allergies

None of the above

Other medical condition

2. Please explain any physical conditions you selected above, including relevant medical history, severity, and current status.*

3. Have you recently experienced any of the following in the past 2 years? (click all that apply)*

Accident or injury

Illness or infection

Surgery

Medical or dental procedure

None of the above

4. If you checked any, please briefly explain and include dates:*

Section 3: Medications, Supplements & Substance Use

1. Are you currently taking or have you taken any of the following in the last 30 days? (click yes to all that apply)*

SSRIs (e.g., Prozac, Paxil, Zoloft)

MAOIs (e.g., Nardil, Marplan)

Benzodiazepines (e.g., Ativan, Xanax, Valium)

Antipsychotics or mood stabilizers (e.g., lithium, Seroquel)

Opioids (e.g., Oxycodone, Vicodin)

GLP-1 agonists (e.g., Ozempic, Wegovy, Mounjaro)

Anti-hypertensives (blood pressure medication)

Diabetes medications (e.g., Metformin, insulin)

Steroids (e.g., prednisone, Albuterol)

Antihistamines (e.g., Benadryl, Claritin)

Antibiotics (e.g., Amoxicillin, Cipro)

Other (please specify below)

I have not taken any of these medications in the past month

2. If you checked 'Other', please list all other prescription, OTC, or natural medications you are currently taking.

3. Are you currently taking any other medications, supplements, peptides, or substances regularly?*

Yes

Please list all that apply

Section 4: Mental & Emotional Health

1. Have you ever been diagnosed with or experienced any of the following? (click all that apply)*

Anxiety

Depression

PTSD or trauma-related condition

Bipolar disorder

Borderline personality disorder

Paranoid personality disorder

Schizophrenia or schizoaffective disorder

Psychosis or psychotic episode

Dissociative symptoms or disorder

History of problematic, abusive or addictive substance use (alcohol, drugs, etc.)

Other (please specify below)

None of the above

2. If you selected any, please include diagnosis (if applicable), timing, and current treatment or status:

3. Have you ever experienced dissociation, psychotic episodes, or nervous system overwhelm during an altered state?*

Yes

4. If yes, please briefly explain and include dates:

5. Have you ever been hospitalized or placed on an involuntary psychiatric hold? *

Yes

6. If yes, please briefly state what happened, when and where it occurred, and your current mental health status:

7. Are you currently in therapy or receiving mental health care?*

Yes

8. If yes, please share what kind of care you’re receiving (e.g., therapy, psychiatry, support groups), how long you’ve been in care, and anything else you feel is relevant.

Section 5: Trauma History

1. Have you experienced any of the following traumatic events? (click all that apply)*

Physical violence

Sexual assault

Verbal/emotional abuse

Death/loss of a loved one

Car accident

Sports injury

Natural disaster

Combat/war

No trauma history

Other trauma

2. If you checked any, please briefly explain and include dates:*

3. Before the age of 18, did you experience any of the following? (click all that apply)*

I didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or care for me.

I lost a parent through divorce, abandonment, death, or other reasons.

I lived with someone who was depressed, mentally ill, or who attempted suicide.

I lived with someone who had a problem with alcohol or drug use (including prescription drugs).

My parents or other adults in the home physically hurt each other.

Someone in my household went to jail or prison.

A parent or adult in the home regularly insulted, shamed, or verbally abused me.

A parent or adult in the home physically hurt me on one or more occasions.

I felt that no one in my family loved me or thought I was special.

I experienced unwanted sexual contact (e.g., fondling, oral/anal/vaginal penetration).

None of the above

4. If yes, please explain:*

Section 6: Psychedelic & Ceremonial Experience

1. Have you ever participated in a facilitated psychedelic ceremony or group experience?**

Yes, multiple times

Yes, once

2. What is the largest dose of psilocybin you have ever taken?*

I have only microdosed

Less than 1 gram

1–2 grams

2–4 grams

More than 4 grams

None

3. How many times have you taken a dose of psilocybin above 2 grams?*

0 times

1 time

2–4 times

5+ times

4. Describe other psychedelic substances you have consumed and approximately what timeframe?*

5. Describe your most meaningful experience, why, and what type of psychedlic.*

6. Have you ever had an adverse reaction to a psychedelic substance or plant medicine that resulted in destabilization or harm?*

Yes

7. If yes, please state the substance, when it occurred, and the nature of your reaction:

8. Are you currently or have you had a micro/mini dose practice? If yes, please describe your experience.*

Section 7: Final Declarations

1. Are there any other health conditions or factors that might affect your participation in sessions? Is there anything else you'd like us to know about your health, intentions, or overall preparedness?*

By signing below, I confirm that all information provided in this form is complete and accurate to the best of my knowledge. I understand that it is my responsibility to fully disclose any relevant health information, and that failure to do so may impact my ability to participate safely.

Date

Month

Day

Year

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.