Therapeutic Medicine Journey

Therapeutic Medicine Journey Intake Form

Please complete this questionnaire thoroughly so we can help you have a safe and beneficial experience. It’s very important that we are aware of your medical conditions, medications, supplements, life experiences, and dispositions that may influence you. This is a confidential record.

Full Name

Referred By

Physical Address

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Phone

Occupation

Age

Purpose

What are your reasons for doing this work? What are your goals, hopes and intentions?

Is there a place in your life where you feel stuck?

Do you have any fears or concerns about doing a journey at this moment in your life?

Journey Experience

Have you had any experience with medicine journeys? If no, skip to the next section.

Yes

What types of journeys have you experienced? Were they recreational or ceremonial?

Have you had any challenging or problematic journey experiences? If yes, please describe.

During journeys, what types of personal issues have you worked through? What insights have you had?

What influence have these journeys had on your life?

Trauma

Pre-Birth, Birth, and Infancy:

Were any traumas or hardships suffered by either parent during your gestation?

Are you aware of any complications with your birth?

As an infant, did you spend any time in an incubator? Why and for how long?

Were you breastfed as an infant?

Yes

Childhood:

In your childhood relationship with your parents, did you feel…

Unloved

Unseen

Unsupported

Not wanted

Neglected

Emotionally unmet

Misunderstood

Shamed

Disempowered

Did a parent or other adult in the household ever hit, slap, or physically hurt you?

Yes

Did you ever witness an adult in your home being physically hurt by another adult?

Yes

Did you live with anyone who was addicted to alcohol or other drugs?

Yes

Did you live with anyone who was mentally ill or had a serious emotional problem?

Yes

Did a parent or other adult in the household ever sexually abuse you?

Did you ever feel that you didn’t have enough food to eat, that you didn’t have a safe place to live, or that you didn’t have clean clothes to wear?

Did your parents or other adults in your home ever go to jail or prison?

Yes

Did you ever witness someone being badly hurt, shot, stabbed, or killed?

Adulthood:

In your adulthood, have you ever felt mentally, emotionally, or physically abused?

Have you had physical trauma such as accident, rape, mugging, or robbery?

Yes

Have you experienced any mental or emotional trauma, such as witnessing harm, violence, or death?

Yes

Do you have difficulty trusting others or life?

Yes

How often do you feel extremely stressed? What things tend to stress you the most?

How do you cope with stress and challenges in your life?

Have you ever been involved in a lawsuit, bankruptcy, or divorce?

Relationships

In your family of origin...

How many siblings did you have? What was your birth order?

Are your parents living? How old were you when they passed?

Describe your relationships with your parents currently or when they were alive: Are your parents separated? If so, how did that affect you?

How supported by your family do you currently feel?

Is there anything about your family of origin we should know about? Neglect, violence, deaths, alcohol, religious oppression, absent parent, depressed parent, mentally unstable parent?

Do you feel comfortable asking your family for help if needed?

Yes

Who is looking out for you?

Are you in an intimate relationship? If yes, for how long? How satisfied are you with that relationship?

Children, if any: Are those children with your current partner?

Do you have close friends with whom you can share your personal process?

Are you part of specific groups or communities? Are you satisfied with those relationships?

Uniqueness

Do you know your Enneagram type, Meyers-Briggs, Human Design, Strengthsfinders, Kolbe, D.I.S.C., or any other personality profile you feel is helpful?

Describe your personality at age 20 and today:

If you’re open to it, please provide your date, time, and place of birth so we can view your astrological birth chart

Please tell us at least 5 things that make you unique:

Please describe your special interests:

On a 1-10 scale, how free do you feel to speak and live your authentic truth?

Mental & Emotional Health

In general, how satisfied are you with your life?

To what extent do you have the symptoms listed below?

Anxious, nervous:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Depressed or Hopeless outlook:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Poor memory:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Lonely:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Angry outbursts or Bad temper:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Easily stressed:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Have you ever had a psychotic episode, experience fear or chronic paranoia, OCD or disturbing repetative or suicidal thoughts?

Have you ever attempted suicide?

Do you have any current or past psychological or psychiatric conditions or diagnoses? Please describe:

Do you currently see any type of mental health counselor? If Yes, for what reason and how often? How long have you been in treatment?

If No, have you seen one in the past? What was the reason and how long were you in treatment?

Have you ever been hospitalized for a psychiatric condition? If yes, please describe:

Food & Substance Use

Do you use food to cope with difficult emotions? Do you have (or have you had) an eating disorder?

How much water do you drink daily?

Do you eat grapefruit or grapefruit juice regularly?

Yes

How much of the following do you consume on average per day? Tobacco or nicotine: Coffee or tea: Alcohol: Marijuana:

Please describe your drug/alcohol use throughout your life and especially during the past three months:

Have you had any adverse physical reactions to alcohol, drugs, or psychedelics?

Do you have any history of substance abuse? Have you ever been treated for substance abuse?

Physical Health History

How would you describe your overall health?

What is your current body height: Weight: Are you satisfied with your current weight?

Do you currently have any medical conditions? Please describe:

Are you currently in the care of a healthcare professional?

Yes

When was your last complete physical exam (month/year)?

Do you have a history or present condition of high or low blood pressure or abnormal heart rhythm?

Might you currently be pregnant?

Yes

Describe any surgeries, major accidents, or hospitalizations:

Have you had any history of seizures?

What medications are you currently taking? (It is essential that you list ALL Rx meds):

Are you more or less sensitive to medications than most people? If so, please describe:

Please list any allergies you’re aware of:

How many hours do you sleep per night? Do you wake refreshed?

Do you have difficulty falling asleep? Difficulty staying asleep?

How often do you exercise and for how long each time?

Are you able to carry a bag of groceries up a flight of stairs without needing to take a break? Are you satisfied with your level of fitness?

Spirituality & Self-Care

Do you feel you have enough free time for yourself? How do you spend your free time?

How good are you at remaining present with your own discomfort?

Do you have a meditation practice?

How much time do you spend in nature per week?

How would you describe your spiritual beliefs and practices?

Do you have other self-care practices? How do you nurture yourself?

Work Life

Do you enjoy the work you do? How fulfilling does your work feel to you?

Is the work you do aligned with your soul, or purpose?

Do you feel supported in your work environment?

Emergency Contacts

We do our best to assure a safe and beneficial experience, yet there are risks associated with this work. Please provide contact information for at least one trusted person who could come to your location within 15 minutes should you need assistance.

Emergency Contact #1 Name: Relationship: Cell phone:

Emergency Contact #2 Name: Relationship: Cell phone:

Waiver of Responsibility

I understand that Regina Chaylee is not a medical or mental health professional and as such cannot diagnose or treat any medical or mental health condition. I take full responsibility for my own independent decision to locate, purchase, and ingest a psychedelic substance for my own reasons. I understand that Regina Chaylee is a personal and relationship development coach and that it’s my choice how I might work with any suggestions or feedback she may offer. I release Regina Chaylee and her company Regina Chaylee LLC from any liability in my interactions with her. *

I understand & agree

Signature Date *

Signature *

Clear

Therapeutic Medicine Journey Intake Form

Full Name

Referred By

Physical Address

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Phone

Occupation

Age

Purpose

What are your reasons for doing this work? What are your goals, hopes and intentions?

Is there a place in your life where you feel stuck?

Do you have any fears or concerns about doing a journey at this moment in your life?

Journey Experience

Have you had any experience with medicine journeys? If no, skip to the next section.

Yes

What types of journeys have you experienced? Were they recreational or ceremonial?

Have you had any challenging or problematic journey experiences? If yes, please describe.

During journeys, what types of personal issues have you worked through? What insights have you had?

What influence have these journeys had on your life?

Trauma

Pre-Birth, Birth, and Infancy:

Were any traumas or hardships suffered by either parent during your gestation?

Are you aware of any complications with your birth?

As an infant, did you spend any time in an incubator? Why and for how long?

Were you breastfed as an infant?

Yes

Childhood:

In your childhood relationship with your parents, did you feel…

Unloved

Unseen

Unsupported

Not wanted

Neglected

Emotionally unmet

Misunderstood

Shamed

Disempowered

Did a parent or other adult in the household ever hit, slap, or physically hurt you?

Yes

Did you ever witness an adult in your home being physically hurt by another adult?

Yes

Did you live with anyone who was addicted to alcohol or other drugs?

Yes

Did you live with anyone who was mentally ill or had a serious emotional problem?

Yes

Did a parent or other adult in the household ever sexually abuse you?

Did you ever feel that you didn’t have enough food to eat, that you didn’t have a safe place to live, or that you didn’t have clean clothes to wear?

Did your parents or other adults in your home ever go to jail or prison?

Yes

Did you ever witness someone being badly hurt, shot, stabbed, or killed?

Adulthood:

In your adulthood, have you ever felt mentally, emotionally, or physically abused?

Have you had physical trauma such as accident, rape, mugging, or robbery?

Yes

Have you experienced any mental or emotional trauma, such as witnessing harm, violence, or death?

Yes

Do you have difficulty trusting others or life?

Yes

How often do you feel extremely stressed? What things tend to stress you the most?

How do you cope with stress and challenges in your life?

Have you ever been involved in a lawsuit, bankruptcy, or divorce?

Relationships

In your family of origin...

How many siblings did you have? What was your birth order?

Are your parents living? How old were you when they passed?

Describe your relationships with your parents currently or when they were alive: Are your parents separated? If so, how did that affect you?

How supported by your family do you currently feel?

Is there anything about your family of origin we should know about? Neglect, violence, deaths, alcohol, religious oppression, absent parent, depressed parent, mentally unstable parent?

Do you feel comfortable asking your family for help if needed?

Yes

Who is looking out for you?

Are you in an intimate relationship? If yes, for how long? How satisfied are you with that relationship?

Children, if any: Are those children with your current partner?

Do you have close friends with whom you can share your personal process?

Are you part of specific groups or communities? Are you satisfied with those relationships?

Uniqueness

Do you know your Enneagram type, Meyers-Briggs, Human Design, Strengthsfinders, Kolbe, D.I.S.C., or any other personality profile you feel is helpful?

Describe your personality at age 20 and today:

If you’re open to it, please provide your date, time, and place of birth so we can view your astrological birth chart

Please tell us at least 5 things that make you unique:

Please describe your special interests:

On a 1-10 scale, how free do you feel to speak and live your authentic truth?

Mental & Emotional Health

In general, how satisfied are you with your life?

To what extent do you have the symptoms listed below?

Anxious, nervous:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Depressed or Hopeless outlook:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Poor memory:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Lonely:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Angry outbursts or Bad temper:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Easily stressed:

Rare
Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Have you ever had a psychotic episode, experience fear or chronic paranoia, OCD or disturbing repetative or suicidal thoughts?

Have you ever attempted suicide?

Do you have any current or past psychological or psychiatric conditions or diagnoses? Please describe:

Do you currently see any type of mental health counselor? If Yes, for what reason and how often? How long have you been in treatment?

If No, have you seen one in the past? What was the reason and how long were you in treatment?

Have you ever been hospitalized for a psychiatric condition? If yes, please describe:

Food & Substance Use

Do you use food to cope with difficult emotions? Do you have (or have you had) an eating disorder?

How much water do you drink daily?

Do you eat grapefruit or grapefruit juice regularly?

Yes

How much of the following do you consume on average per day? Tobacco or nicotine: Coffee or tea: Alcohol: Marijuana:

Please describe your drug/alcohol use throughout your life and especially during the past three months:

Have you had any adverse physical reactions to alcohol, drugs, or psychedelics?

Do you have any history of substance abuse? Have you ever been treated for substance abuse?

Physical Health History

How would you describe your overall health?

What is your current body height: Weight: Are you satisfied with your current weight?

Do you currently have any medical conditions? Please describe:

Are you currently in the care of a healthcare professional?

Yes

When was your last complete physical exam (month/year)?

Do you have a history or present condition of high or low blood pressure or abnormal heart rhythm?

Might you currently be pregnant?

Yes

Describe any surgeries, major accidents, or hospitalizations:

Have you had any history of seizures?

What medications are you currently taking? (It is essential that you list ALL Rx meds):

Are you more or less sensitive to medications than most people? If so, please describe:

Please list any allergies you’re aware of:

How many hours do you sleep per night? Do you wake refreshed?

Do you have difficulty falling asleep? Difficulty staying asleep?

How often do you exercise and for how long each time?

Are you able to carry a bag of groceries up a flight of stairs without needing to take a break? Are you satisfied with your level of fitness?

Spirituality & Self-Care

Do you feel you have enough free time for yourself? How do you spend your free time?

How good are you at remaining present with your own discomfort?

Do you have a meditation practice?

How much time do you spend in nature per week?

How would you describe your spiritual beliefs and practices?

Do you have other self-care practices? How do you nurture yourself?

Work Life

Do you enjoy the work you do? How fulfilling does your work feel to you?

Is the work you do aligned with your soul, or purpose?

Do you feel supported in your work environment?

Emergency Contacts

Emergency Contact #1 Name: Relationship: Cell phone:

Emergency Contact #2 Name: Relationship: Cell phone:

Waiver of Responsibility

I understand & agree

Signature Date *

Signature *

Clear

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Details of the bonus

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