LIFEology Intake Flow

Who should we thank for your interest in LIFEology?

This helps you connect with your LIFEology family.

Referral source

Who invited you? Search by their name — you don't need their username

✓

Type the name of the person who invited you. We'll show matching members so you can tap the right one.

Let's begin with your name

We'll use this to personalize your care plan.

Full legal name Preferred name

Identity details

We use this to tailor your care appropriately.

Date of birth Age Gender

Where can we reach you?

We'll only use this for care coordination.

Home address City / State / ZIP Email address Phone number

Relationship & work

Share only what you feel comfortable with.

Marital / relationship status Employer (if applicable)

Emergency contact

Someone we can reach if needed.

Emergency contact name Emergency contact relationship Emergency contact phone number

Primary Life Details

Helpful for coordination with your LIFEology guides.

Primary care physician Physician phone number Height Weight

Pregnancy / breastfeeding

Currently pregnant Currently breastfeeding Not applicable

General Life History

Let us know about your history.

I have diagnosed medical conditions If yes, list diagnoses, dates, and current status I am currently under medical treatment or monitoring If yes, explain

Basic information checklist

Only select what applies.

I have had hospitalisation or surgery in the past 12 months If yes, include dates and details

Mental health history

Select any diagnoses you've received.

I have been diagnosed with a mental health condition

Diagnoses (tick all that apply)

Depression Anxiety disorder Bipolar disorder PTSD OCD Psychosis or schizophrenia ADD / ADHD History of psychiatric admission Other (specify)

Current mental health support

Help us understand your present support network.

I am currently seeing a mental health professional Provider type, name, and frequency I have experienced a significant emotional or psychological crisis in the past 12 months Describe I am currently experiencing thoughts of self-harm or harm to others If yes, describe thoughts, intent, and current safety

Medication & supplements

List everything you're currently taking.

List all prescription medications currently taken I take over-the-counter medications or supplements List all supplements, herbal products, or non-prescription medicines I have experienced adverse reactions to medications or anaesthesia Describe reaction and substance

Substance use history

This helps us tailor safe, effective sacrament.

Alcohol use Recreational drug use Prescription medication misuse

If yes to any above, specify substance(s), frequency, duration, and last use History of substance dependence or addiction treatment Type of treatment and dates History of withdrawal symptoms Describe symptoms experienced Currently engaged in recovery support Specify counselling, medication-assisted treatment, or groups Prior experience with ketamine or psychedelic-assisted therapy Describe experience and outcomes

Support systems & safeguarding

Let us know who's supporting you right now.

Currently engaged with healthcare or social support services List providers or organisations I have a crisis contact person Name and contact details

Life goals & expectations

Tell us what you want to feel different.

What support are you seeking at this time? What outcomes or improvements are you hoping to achieve? I have tried mental health or addiction treatments previously Describe what worked or did not work

Risk awareness

These acknowledgements help us keep you safe.

I understand the importance of following all recommended instructions I am able to comply with programme structure and restrictions I currently have concerns about my own safety or emotional stability

If yes, explain

Legal & consent

Please review these consent statements carefully.

I am 18 years of age or older I understand sacrament does not replace emergnecy medical care I consent to the collection and secure storage of my personal information I understand the risks, benefits, and alternatives to sacrament.

Signature (type your full name) Date

Review & submit

You can always go back and make edits.

Ready to submit?

When you submit, your answers are packaged for the care team. A confirmation summary will appear on screen.

By submitting, you confirm the information is accurate and complete to the best of your knowledge.

Welcome to LIFEology

Progress

Who should we thank for your interest in LIFEology?

Let's begin with your name

Identity details

Where can we reach you?

Relationship & work

Emergency contact

Primary Life Details

General Life History

Basic information checklist

Medical history checklist

Mental health history

Diagnoses (tick all that apply)

Current mental health support

Medication & supplements

Substance use history

Support systems & safeguarding

Life goals & expectations

Risk awareness

Legal & consent

Review & submit

Ready to submit?

Welcome to the LIFEology Family!

Who should we thank for your interest in LIFEology?

Let's begin with your name

Identity details

Where can we reach you?

Relationship & work

Emergency contact

Primary Life Details

General Life History

Basic information checklist

Medical history checklist

Mental health history

Diagnoses (tick all that apply)

Current mental health support

Medication & supplements

Substance use history

Support systems & safeguarding

Life goals & expectations

Risk awareness

Legal & consent

Review & submit

Ready to submit?

Statement of Beliefs

Welcome to the LIFEology Family!