intake-form | Iamjonikim

Have an account?

Hello, and welcome!

I’m so glad you’re choosing to show up for yourself.

This questionnaire helps me understand where you are in your journey and whether this container is the right fit for you right now.

Please answer as honestly and thoroughly as you can. There are no right or wrong answers.

All information is kept private and confidential.

Section 1 - Basic Information

1. Full Name

First name

Last name

2. Email and Phone Number

Preferred Email

Phone

3. Age Range

4. Country of Residence

5. How did you hear about this experience?

Section 2 - Timing & Commitment

6. When are you hoping to begin?

As soon as possible

Within the next few months

I’m not sure yet

7. Time you can dedicate between sessions for practices & integration:

Less than 1 hour per week

1–3 hours per week

As much time as needed to make progress

Section 3 - Services of Interest

8. What are you most curious about? (Choose all that apply)

Section 4 - Intentions & Goals

9. What is your primary goal for this work?

10. What feels like the biggest obstacle to that goal right now?

Section 5 - Your Current Well-Being

11. Where are you in your personal growth or healing journey?

12. What spiritual, reflective, or contemplative practices support you?

(e.g., meditation, therapy, yoga, prayer, journaling)

Section 6 - Psychedelic Experience

13. Have you previously worked with psychedelics? (Choose all that apply)

Section 7 - Substance Use

14. Please describe which psychoactive substances you have worked with and how recent?

15. Have any experiences with these substances been difficult or destabilizing?

No

Yes

Section 8 - Medication (Important for Safety)

16. Are you currently taking any of the following?

Section 9 - Mental Health History

17. Have you ever received a diagnosis of:

18. Have you ever been prescribed medication for mental or behavioral health?

No

Yes

Section 10 - Physical Health

19. Any medical conditions we should be aware of? Are you taking medications for physical health?

20. Are there any diet restrictions or food preferences. Please list here.

Section 11 - Anything Else

21. Is there anything important about you that hasn’t been asked?

22. Photo & Media Consent - I understand that my image may be taken during events.

I consent to photos/videos for group use only (private)

I consent to photos/videos for promotional use (public)

I do not consent to any photos/videos

Maybe with prior approval

Section 12 - Investment Range

21. For a 3–6-month engagement, which feels most accurate?

Budget is not a limiting factor

$2,501 – $7,500

Under $2,500

Coaching Relationship & Disclaimer

Coaching is a collaborative, growth-oriented process designed to support insight, behavior change, and integration. Coaching is not psychotherapy, medical treatment, or crisis care. If needs arise that fall outside the scope of coaching, referrals to appropriate licensed professionals may be recommended. Nothing in this relationship should be construed as medical or psychological advice.

Honesty & Communication Agreement

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that honest communication helps create the safest and most supportive container for this work.

Honesty & Communication Agreement

I Agree

I Do Not Agree

Name

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