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Truffle Treatment Screening Questionnaire

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.

⏲ Takes 10+ minutes

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1

Name

2

Age

3

Gender

4

Email address

5

Phone number

6

Trusted support contact (name, relationship, phone number)

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 session or 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 with, or do you suspect you have, any of the following medical conditions?

Select one or more answers
9

Are you currently under the care of a doctor or medical specialist? If yes, please describe your condition and treatment.

10

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

11

Have you (or a close relative) ever been diagnosed with, or experienced symptoms consistent with, any of the following?

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

Are you currently experiencing suicidal thoughts or have you attempted suicide in the past? If so, please describe in detail.

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.

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.

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.

23

Have you ever struggled with substance dependence or addiction? Please describe in detail.

Current Intentions & Journey Experience

24

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

25

Have you used any of the following previously?

Select one or more answers
26

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?

27

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.

Lifestyle

28

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

Select one or more answers
29

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

30

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

31

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

32

How do you take care of yourself when life becomes challenging or stressful? What helps you "fill up your cup" and return to balance?

Social History, Support Network, & Integration


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

33

Which of the following describes your current relationship status?

Select one answer
34

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

35

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

Current Emotional Wellbeing

The following questions are intended to give me a better understanding of how you've been feeling over the past 2–4 weeks.

36

Mood How often have you been bothered by the following over the past 2-4 weeks?

Select one answer in each row
37

Anxiety

Select one answer in each row
38

Please indicate what type of session you are interested in:

Select one answer
39

Would you share how did you find me?

Select one or more answers
40

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

Informed Participation

41

By submitting this form, I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that honest disclosure is essential in assessing the safety and suitability of my participation. I understand that participation in a psilocybin session is voluntary and may involve intense physical, emotional, and psychological experiences. While many people find these experiences meaningful and beneficial, no specific outcome or therapeutic result can be guaranteed. I understand that this experience is intended for personal growth and self-exploration and does not replace medical, psychiatric, or psychological care. I remain responsible for consulting my physician regarding any medical conditions or prescribed medications. I agree to inform the facilitator of any significant changes to my health, medication use, or personal circumstances before the session. I have read and agree to the Terms & Conditions and choose to participate voluntarily, accepting personal responsibility for this decision.

Please select one:

Thank you!