.

Truffle Treatment Screening Form

Your Screening Questionnaire data will be handled to the highest standards of confidentiality. We store your answers in compliance with GDPR and will only use your data for assessment purposes.

Secured
Survio
Create a survey
Truffle Treatment Screening Form
1

Name

2

Age

3

Gender

4

Email address

5

Phone number

6

Trusted support contact (name, relationship, phone number)

Create a survey
Truffle Treatment Screening Form

Health History


The following questions are designed to assess if your mental and physical health meet the baseline safety criteria required for participating in a psychedelic supported retreat.

7

Are you allergic to something? Please provide a description of the allergy or intolerance as well as the reaction you have.

8

Have you ever been diagnosed or suspect you have any of the following medical conditions?

Select one or more answers
9

Do you have any other medical conditions? If so, are you currently in the care of a health care professional? Please describe in detail.

10

Do you currently see a psychologist, psychiatrist or a counselor? If so, how often and how long?

Create a survey
Truffle Treatment Screening Form
11

Have you (or a close relative) ever been diagnosed or suspect to suffer from any of the following psychiatric conditions?

Select one or more answers
12

Please describe in detail any psychiatric condition you have checked in the previous question.

13

Have you ever been hospitalised for a psychiatric reason? If so, please describe in detail.

14

Do you currently have suicidal thoughts or have you made a suicide attempt? If so, please describe in detail.

Create a survey
Truffle Treatment Screening Form
15

Do you/have you taken any of the following medications regularly?

Select one answer in each row
16

Do you currently use any prescription medication? If so, please include a full list of your prescription medications including name, dose, for how long and any adverse reactions or side effects.

Create a survey
Truffle Treatment Screening Form
17

Do you/have you taken any of the following supplements regularly?

Select one answer in each row
18

Do you currently use any over the counter OTC medications, vitamins, minerals, herbal products, homeopathic, or other health aids? If so, please include a full list including name, dose, for how long and any adverse reactions or side effects.

Create a survey
Truffle Treatment Screening Form

Substance Use


The following questions are designed to understand more about your history and relationships to various substances 

19

Please indicate the correct answer regarding your use of alcohol.

Select one answer
20

Do you smoke or use tobacco products? If so, what kind of tobacco products do you use? How often and for how long?

21

Have you used any of the following substances in the past 3 months?

Select one or more answers
22

If you indicated any substance use in the previous question, please describe in detail how much of each substance and how often did you use it.

Create a survey
Truffle Treatment Screening Form

Current Intentions & Journey Experience

23

Please share your intentions for this session. What do you wish or hope to gain from this experience?

24

Have you used any of the following previously?

Select one or more answers
25

If you indicated any use of substances in the previous question, please describe the type of substance taken, the dose and the situation or purpose of taking the substance. Has it been in a recreational or a ceremonial context?

26

Have you had any adverse reactions, challenging or problematic experiences with conscious-altering substances? Please describe the practice or type of substance taken, the dose and the situation or purpose of taking the substance.

Create a survey
Truffle Treatment Screening Form

Lifestyle

27

Do you have experience with altered states of consciousness through other practices?

Select one or more answers
28

How would you describe your sleep quality? How many hours of sleep do you typically get?

29

How would you describe your diet? Do you feel nourished by the food you eat?

30

How would you describe your physical activity? Do you feel like you move your body enough?

31

How do you take care of yourself? What do you do to "fill up your cup"? How do you come back into/maintain balance in your life?

Create a survey
Truffle Treatment Screening Form

Social History, Support Network, & Integration


The following questions will help understand more about your current social situation and support network

32

Which of the following describes your current relationship status?

Select one answer
33

Are there any major sources of stress in your life at the moment or events that have occurred recently and have impacted your health?

34

Do you have a support structure in your life? Which of the following do you consider your support network? Please select all options you use for support of your health needs.

Select one or more answers
Create a survey
Truffle Treatment Screening Form

Current Symptoms


The following questions are designed to create a snapshot of how you've been feeling over the last 2-4 weeks

35

Survey of Depression Symptoms Please complete the following questions based upon how you've been feeling over the past 2 to 4 weeks

Select one answer in each row
36

Survey of Anxious Symptoms Please complete the following questions based upon how you've been feeling over the past 2 to 4 weeks

Select one answer in each row
Create a survey
Truffle Treatment Screening Form
37

Please indicate what type of session you are interested in:

Select one answer
38

Is there anything else you would like to mention? Please share anything you feel is important for me to know about you.

Create a survey
Truffle Treatment Screening Form

Thank you!

Create a survey