Shepherd-U Holdings, LLC

Health Screening Form

Full Name

Date of birth *

OCCUPATION: *

MARITAL STATUS: *

Address *

Street Address

City

State

Country

Postal code

Phone *

Email *

Emergency Contact (Required)

Their Name: *

Their Cell Phone: *

Their Email: *

Their Address: *

RELATIONSHIP TO YOU: *

What is the nature of your interest in this program? *

Please list ALL of your medical providers, including current therapists/counselors: *

Medical Conditions

Are you pregnant, breastfeeding, or trying to become pregnant? *

Do you have any allergies? (If yes, to what?)

Psychological/Psychiatric Conditions

Have you ever been hospitalized for psychiatric treatment? *

Have you ever/do you currently have hallucinations, paranoid thoughts, or hear voices that are not there? *

Do you dissociate or “lose time”? *

Have you experienced significant emotional, physical, or sexual trauma in your life? *

Have you ever attempted suicide? *

Have you ever/do you currently engage in self-harm behaviors? *

Please list ALL Medications you are taking: *

Please list all SUPPLEMENTS you are taking: *

Please list ALL psychiatric medications you have been prescribed in the past 5 years: *

Please comment on your current emotional state: *

How would you assess your overall sense of well-being and emotional state in the past 6 months? *

Is there any other information to include regarding your physical or emotional well-being: *

Substance Use

Have you ever been charged or convicted of a felony? *

Do you drink alcohol? *

How much and how often?

Have you ever had withdrawal from alcohol?

Have you ever been treated for alcohol use?

Do you smoke cigarettes or use nicotine in other forms? *

How much and how often do you smoke cigarettes or use nicotine in other forms?

Do you use cannabis for legally permitted purposes? What is the purpose? *

How much do you use (frequency and how do you use it, ie smoking, vaping, edibles, other)? What is the effect on you?

Other Substance/Drug Use

Current: What substances/drugs are you currently using? *

Substances/Drugs
How frequent?
How much?

Past: What substances/drugs have you used in the past? *

Substances/Drugs
How frequent?
How much?

Prior entheogen, psychedelic, or hallucinogen use

What’s the nature of your prior use? *

When was the last time (date)? *

Have you ever had a long-lasting, negative reaction to an entheogen, psychedelic, or hallucinogen? (If so, what was it?) *

Any dietary restrictions? *

Are you physically active? *

Do you have a regular, spiritual practice or religion with which you identify? *

Do you have supportive friends/family who are aware of your participation in this program? *

Do you have access to professional support (ie therapist/counselor)? *

I acknowledge that I am not allowed to bring weapons to any fellowship activities and if I am trained in fighting/combat, I will notify the support staff ahead of time. *

YES, I AGREE

NO, I DO NOT AGREE

I also consent to have the audio of my sessions recorded. (The recordings are used for your integration purposes. A copy of the audio file will be sent to you a few days after being recorded.)

YES, I AGREE

NO, I DO NOT AGREE

CONFIDENTIAL HEALTH FORM ACKNOWLEDGEMENT

I hereby affirm that the information provided above is complete and accurate. I am providing my current, past, and familial medical, physical, mental, emotional, spiritual, and psychological health conditions, whether known or unknown, and the substances that I am consuming, including but not limited to prescription medications or other drugs, supplements, herbs, food, and any other substances (collectively, my “Health Conditions”) to the best of my ability.

I agree to notify Shepherd-U Holdings, LLC promptly should there be any changes in my Health Condition or to any response to this form.

I understand that the purpose of this form is not to make any medical, therapeutic, or other professional evaluation or diagnosis.

If I have any questions or concerns about any activities or sacrament, I agree it is my responsibility to consult with my physician.

While Shepherd-U Holdings, LLC will keep this form confidential, I understand and acknowledge that it is not a medical record subject to HIPAA.

Signature: *

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Full Legal Name: *

Today's Date:

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