Name
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First Name
Last Name
Email
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Phone
(###)
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Date of Birth
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MM
DD
YYYY
Relationship Status
How would you describe your current chapter of life in a sentence or two?
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What feels most alive for you in your life right now?
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What feels most stuck in your life right now?
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What are your biggest daily stressors or recurring challenges?
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On a scale of 1–10, how aligned do you feel with your values and truth?
On a scale of 1–10, how fulfilled do you feel in your life overall?
What drew you to microdosing—and to this mentorship specifically?
What are your top intentions for this journey?
What are you hoping will shift internally (within yourself)?
What are you hoping will shift externally (your work, habits, relationships, lifestyle)?
What 2–3 outcomes would make this program feel deeply worth it?
What life experiences have most shaped who you are?
Have you experienced trauma, major transitions, loss, or illness?
Are you currently receiving any support (therapy, coaching, community, bodywork, spiritual, etc.)?
What’s your relationship to personal growth? Any patterns, blocks, or breakthroughs worth noting?
How would you describe your relationship to yourself?
How would you describe your relationship to others (family, friends, romantic)?
Are there relational patterns you're ready to shift (e.g., people-pleasing, overgiving, avoidance)?
What is your current work/professional situation?
Does your work feel aligned with your gifts or soul purpose?
What would a dream contribution or legacy look like for you?
Are there creative or leadership aspects of you that want more expression?
How would you describe your physical health?
Any chronic symptoms, diagnoses, or energetic patterns worth noting?
Do you take any medications (especially SSRIs, mood stabilizers, etc.) or supplements?
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Any history of eating disorders, substance use, or burnout?
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desribe
How do you feel in your body day to day—grounded, anxious, energized, disconnected?
Have you microdosed before? If yes, what was your experience like?
Have you done high-dose work? (Which medicines, how many times, what contexts?)
Have you had any challenging or unresolved psychedelic experiences?
Do you identify as spiritual or feel connected to something greater?
Do you have spiritual or energetic practices (meditation, astrology, energy work, prayer, etc.)?
Which practices have you NOT practiced, but are interested in
Do you feel connected to your intuition or inner knowing?
How would you describe your true essence or personality?
Are you living as your full, authentic self right now?
If not, how?
Have you had to shut down or hide parts of yourself in the past?
If so, which parts and why?
What aspects of you are longing to be reclaimed or expressed?
What excites you most about this journey?
Are there any fears or resistances coming up as we begin?
What kind of support do you respond best to?
check all that apply
Are you fully committed to showing up for this process with honesty and presence?
Yes
No
What does your aligned life look and feel like?
If you could shift one area of your life immediately, what would it be?
What is your soul most craving right now?
Who are you becoming through this process?
How do you want to feel by the end of the mentorship?
Is there anything else you'd like me to know about you or your needs before we begin?
