Pre-consultation: Psychedelic Medicine

First name *

Last name *

Email *

Phone *

Date of birth *

What condition are you seeking treatment for? *

Treatment-resistant depression

PTSD

End-of-life anxiety

Cluster headaches

Existential distress

Addiction

Personal growth/exploration

Other

How long have you been living with this condition? *

Less than 6 months

6-12 months

1-2 years

2-5 years

More than 5 years

Severity of your condition: *

Mild

Moderate

Severe

Life-altering

Have you ever been diagnosed with any of the following? *

Depression

Anxiety

Bipolar disorder

Schizophrenia

Schizoaffective disorder

Psychotic episode

Personality disorder

OCD

Eating disorder

ADHD

Autism

None

Schizophrenia, schizoaffective disorder, or previous psychotic episode?

Psychotic disorders are a relative contraindication to psychedelic therapy. We will discuss alternative approaches if applicable.

Yes

No

Have you been hospitalised for a psychiatric condition? *

Yes

No

Have you ever engaged in self-harm? *

Never

In the past

Currently

Have you experienced suicidal thoughts or urges? *

SAFETY QUESTION: If you are having suicidal thoughts, please reach out to the Samaritans (116 123) or Crisis Text Line immediately

Never

In the past

Occasionally

Frequently

Does anyone in your family have a diagnosis of schizophrenia?

First-degree relatives with schizophrenia are at higher genetic risk for psychotic episodes

Yes

No

Unsure

Does anyone in your family have bipolar disorder?

Yes

No

Unsure

Does anyone in your family have a history of psychosis?

Yes

No

Unsure

Have you used psychedelics before?

Yes

No

Do you currently use recreational drugs?

Yes

No

How would you describe your alcohol consumption? *

Don't drink

Rarely

Moderatly (1-3 units per week)

Frequently (4-7 units per week)

Heavily (8+ units per week)

Do you use cannabis? *

Never

Occasionally

Regularly

Daily

Do you use stimulants (cocaine, amphetamines, prescription stimulants)? *

Never

Occasionally

Regularly

Please list all medications you are currently taking (prescription and over-the-counter), including doses: *

Are you currently taking any SSRIs or SNRIs (antidepressants)? *

SEROTONIN SYNDROME RISK: SSRIs and SNRIs interact with psilocybin. They may need to be tapered before your session. Do NOT stop your medication without medical supervision.

Yes

No

Have you taken any MAOIs (monoamine oxidase inhibitors) in the last 2 weeks? *

ABSOLUTE CONTRAINDICATION: MAOIs in combination with psilocybin create serious serotonin syndrome risk

Yes

No

Are you currently taking lithium? *

ABSOLUTE CONTRAINDICATION: Lithium in combination with psilocybin is unsafe

Yes

No

Are you taking any antipsychotic medications? *

Yes

No

Are you taking benzodiazepines (e.g. diazepam, lorazepam)? *

Yes

No

Do you have high blood pressure?

Psilocybin can increase blood pressure and heart rate

Yes

No

Unsure

Do you have any history of heart disease, arrhythmias, or heart attack? *

Yes

No

Is there a family history of sudden cardiac death? *

Yes

No

Unsure

Do you have access to psychological support for integration sessions after your experience? *

Yes

No

Can you commit to the full treatment programme (preparation, session, and integration) typically lasting 6-8 weeks? *

Yes

No

Do you have reliable transport home after your session? *

You will not be able to drive after your session

Yes

No

Do you have a supportive home environment for your recovery? *

Yes

No

What are you hoping to achieve from psychedelic-assisted therapy? *

How did you hear about psychedelic-assisted therapy at LoveMyLife? *

Search engine

Social media

Friend recommendation

Healthcare provider referral

News/media article

Other

Is there anything else you'd like us to know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Reason for Interest

What condition are you seeking treatment for? -

How long have you been living with this condition? -

Severity of your condition: -

Psychiatric History

Have you ever been diagnosed with any of the following? -

Schizophrenia, schizoaffective disorder, or previous psychotic episode? -

Psychiatric History (continued)

Have you been hospitalised for a psychiatric condition? -

Have you ever engaged in self-harm? -

Have you experienced suicidal thoughts or urges? -

Family Psychiatric History

Does anyone in your family have a diagnosis of schizophrenia? -

Does anyone in your family have bipolar disorder? -

Does anyone in your family have a history of psychosis? -

Psychedelic Experience

Have you used psychedelics before? -

Substance Use

Do you currently use recreational drugs? -

How would you describe your alcohol consumption? -

Do you use cannabis? -

Do you use stimulants (cocaine, amphetamines, prescription stimulants)? -

Current Medications

Please list all medications you are currently taking (prescription and over-the-counter), including doses: -

Are you currently taking any SSRIs or SNRIs (antidepressants)? -

Have you taken any MAOIs (monoamine oxidase inhibitors) in the last 2 weeks? -

Are you currently taking lithium? -

Are you taking any antipsychotic medications? -

Are you taking benzodiazepines (e.g. diazepam, lorazepam)? -

Cardiovascular Safety

Do you have high blood pressure? -

Do you have any history of heart disease, arrhythmias, or heart attack? -

Is there a family history of sudden cardiac death? -

Practical Considerations

Do you have access to psychological support for integration sessions after your experience? -

Can you commit to the full treatment programme (preparation, session, and integration) typically lasting 6-8 weeks? -

Do you have reliable transport home after your session? -

Do you have a supportive home environment for your recovery? -

Motivation & Goals

What are you hoping to achieve from psychedelic-assisted therapy? -

How did you hear about psychedelic-assisted therapy at LoveMyLife? -

Is there anything else you'd like us to know? -

Medical records (optional)

You can upload relevant medical records, psychiatric evaluations, or treatment summaries to help us understand your medical history

Click to upload files

Anything else for your doctor?