Intake Form (Consultation Services)

Emergency Assistance

If this is an emergency, call:

Crisis Line: 988 (National Suicide Crisis line)
New Mexico Crisis Line 1-855-NMCRISIS (662-7474).
911 or go to your nearest hospital emergency room

Client Information

Dear prospective client, all information you send to me will be encrypted over HIPAA-compliant email to protect your privacy. The information I provide to you on psychedelic subject areas is for educational and harm-reduction purposes so that you can make the best choice for your needs. I am an educator in this space and uphold the duties and responsibilities of my licensure as defined in the NASW Code of Ethics as a New Mexico Social Worker (C-08692).

First name

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

Can I contact you by phone, email, text message, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Behavioral Health History

Are you currently seeing a psychotherapist?

Yes No

If yes, what is the therapist's name & how long you have been seeing them?

What has been the focus of your therapy and what about the therapy has been effective or ineffective?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

Do you have any pre-existing medical conditions?

Is there anything else regarding your medical history that I should be aware of?

Community/Support System History

Is there anything regarding your relationships you would like me to be aware of?

Do you have a supportive system (friends, children, siblings, other)?

Yes No

Briefly describe your support system.

Personal History

What is your highest level of education?

Are you currently employed?

Yes No

If yes, what is your current occupation?

Do you currently have stable housing?

Yes No

If you answered no, please describe briefly.

Do you use drugs?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Is there anything else regarding your personal history that I should be aware of?

Reasons for Visit

You are seeking the following services (choose all that apply)

Psychedelic Facilitation Services - preparation, facilitation, integration services

Transformation facilitation

Professional Consultation for psychotherapists, psychedelic facilitators

Describe the reasons you are seeking my services.

Describe any goals or outcomes you hope to achieve from my services.

Describe any significant life changes or stressful events that have caused you to seek support right now.

Is there anything else you'd like to tell me about?

Checkbox

I understand that Amy Wong Hope does not provide psychedelic substances to clients and that any information provided by Amy Wong Hope is for educational purposes. Amy Wong Hope is a licensed Natural Medicine Clinical Facilitator in the state of Colorado.

Your information will be encrypted.