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Kanna Intake Form
First name
*
Last name
*
Email
*
Phone
*
Address
*
Occupation
*
Do you have a job or lifestyle that requires testing for substances in your system (blood, urine, hair)? * If yes, please explain.
*
Emergency Contact (Please include name, phone number & relationship)
*
List any and all medications you are on, past (within the last 6 months) or present. Please list the reason you were prescribed the medication and the dosage.
*
Have you ever been diagnosed with any of the following:
High Blood Pressure
Heart Disease
Seizures/Epilepsy
Kidney Disease
Lung Disease
Cancer
Diabetes
HIV/AIDS
Autoimmune Disease
Arthritis
Fibromyalgia
Asthma
Bleeding Disorder
Gastrointestinal Issues
Hypotension
Thyroid Problems
Migraines
Hypoglycemia
Other
Have you ever been a victim of sexual abuse? If yes, when? Are you currently, or have you previously been in counseling for this event? If not, do you ever feel as if you should be?
Have you ever been in a war zone? If yes, when and where? Have you ever been or are you currently in counseling for this event? If not, do you feel as if you should be? Do you suffer from PTSD due to this event?
*
Have you ever contemplated suicide?
*
Yes
No
Have you ever attempted suicide? If yes, when?
*
Have you ever been in counseling with a psychiatrist, psychologist, or other type of counselor? If yes, when, for what reason, and for how long?
Are you currently in therapy/counseling?
Yes
No
If yes, what are you currently working on with your counselor? Check ALL that apply.
Anxiety
Depression
Marital Problems
Relationships
Career
Grief
PTSD
Substance Abuse
Sexuality
Inspiration
Family Counseling
Court Ordered Counseling
Maintenance
Sexual Trauma
Physical Health Issues
Other
Relationship Status
*
With whom do you live?
Do you smoke cigarettes? If yes, how many cigarettes per day do you smoke? *
*
Do you drink alcohol? If yes, how often? *
*
Have you ever used cannabis in any form? If yes, what effect did it have on you? How frequently do you use it?
*
Have you ever used stimulants such as Ritalin, amphetamines, Adderall, cocaine, etc.? If yes, what effect did they have on you?
*
Did you experience any of the following symptoms? * Check all that apply.
Anxiety
Irregular or fast heartbeat
Euphoria
None of the above
Other
Do you consume other stimulants daily such as coffee or tea? If so, what affect does it have on you? Would you say that you are caffeine sensitive?
*
Have you ever used psychedelics such as psilocybin, ayahuasca, LSD, peyote, etc.? If yes, what effect did it have on you?
*
Have you ever taken narcotics such as Vicodin, Hydrocodone, OxyContin, etc.? If yes, what effect did it have on you?
*
Have you ever been in treatment for substance abuse? If yes, please list when and where and for what substance you were in treatment for.
*
In the last 12 months, have you experienced a significant emotional/traumatic event? If yes, please explain in short detail. * Example: Car accident, DUI, custody battle, divorce, assault, recent death in the family, etc.
*
Is there anything else about your physical or emotional state that you would like your facilitator to know?
*
Submit
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