Intake | Door of Perception

I declare that I have read and understood the general terms and conditions and that I agree to the terms. *

Yes

PERSONAL DETAILS

Name *

Age *

Phone number *

Email address *

BILLING DETAILS

Company name (if applicable)

Street & house number *

Postcode, city & country *

Which rate applies to your situation? *

€1,245 – Standard rate for private individuals
€1,500 – Business rate or private individuals with ample financial means

BACKGROUND

What are you currently doing in terms of work, study, or other daily activities? *

What does your home situation look like? (multiple answers possible) *

I live alone
I live together with my partner
I live with young children
I live with older children (10+)
I live with adult children
I live with other adults
I live with pets

What do you enjoy doing to relax? *

What are important hobbies, interests, or creative outlets in your life? *

Do you play an instrument or do you have a preference for certain music styles? *

MOTIVATIE & INTENTIE

What makes you want to do a truffle session at this moment? *

Breaking a pattern
Exploring personal or psychological themes
Processing experiences from the past
Supporting creativity
Processing loss or grief
Deepening relationships
Strengthening the connection with nature or surroundings
Personal development
Spiritual exploration
Curiosity
Other, namely:

Can you briefly elaborate on your motivation? *

Do you currently have a specific intention for this journey? *

Yes, I'd like to share it during the preparation session
Yes, but I prefer to keep it to myself
Not entirely yet; I could use some help with that

EXPERIENCE & RESOURCES

Do you have experience with psychedelics? *

Yes, a lot
Yes, a little
No

Do you have experience with meditation, mindfulness, or breathwork? *

Yes, a lot
Yes, a little
No

Do you have experience with other forms of altered states of consciousness without substances? (e.g. meditation, breathwork, fasting, sweat lodge, hypnosis, trance work, or holotropic breathwork) *

Yes, a lot
Yes, a little
No

If you answered "yes" to one or more of the above questions: Can you briefly describe what experiences you have had, when this was, and how you look back on them? *

Have you ever had a difficult, overwhelming, or frightening experience with psychedelics or another consciousness-altering method? *

Yes
No

If yes, can you briefly describe what happened and how long the effects lasted?

Are there spiritual, religious, or philosophical beliefs that are important to you and that you would like to incorporate into the preparation or guidance? *

Are there people in your environment with whom you can talk after the session about your experience? *

Yes, friends or family
Yes, colleagues or acquaintances
Yes, a therapist or other counsellor
Maybe
No

Have you informed yourself about the effects of psychedelics and do you broadly know what to expect? *

Yes, through personal experience
Yes, by reading about it, listening to podcasts or conversations with others
No, not that much yet

MEDICAL SCREENING

The following questions are intended to carefully map any potential risks.

I ask you to answer these questions as honestly as possible. During the preparation I will discuss any points of attention with you further.

All information will of course be treated confidentially.

Do you smoke? *

Yes
No, but I used to
No

Are you currently using medication, supplements, or herbal preparations? *

Yes
No
Tot voor kort wel

If yes, which medication or supplements are you using, at what dosage, and since when?

Do you use cannabis on a regular basis and/or do you microdose? *

Yes, cannabis
Yes, microdosing with truffles
Yes, microdosing with other psychedelics
No

How would you describe your mental wellbeing at this moment? *

Mostly good
I am going through a difficult period but functioning reasonably
I am currently experiencing a lot of stress, emotional burden, or psychological complaints
I am sleeping poorly
Other, namely:

Further comments:

Do any of your parents, brothers, or sisters have serious cardiovascular disease before the age of 65? (e.g. heart attack, stroke, or serious cardiac arrhythmia) *

Yes
No
I'm not sure

Have you ever had a psychosis or experienced psychotic symptoms? *

Yes
No

Do any of your parents or siblings have a history of psychosis, schizophrenia, or bipolar disorder? *

Yes
No
I'm not sure

Have you ever had one or more of the following conditions or diagnoses? (multiple answers possible *

Depression
Anxiety disorder
Panic attacks
Psychosis
Trauma / PTSD
Psychotic vulnerability
Schizophrenia
Bipolar disorder
Personality disorder
Problematic alcohol use
Problematic substance use
Epilepsy
High blood pressure
Cardiac arrhythmia
Cardiovascular disease
Diabetes
Brain injury
Major surgery or medical treatment
Other mental health condition
Other physical condition
None of the above

Further comments

Are you pregnant or breastfeeding? *

Yes
No
Not applicable

For participants aged 65 and older, I sometimes ask for a prior medical check-up or approval from a GP or treating physician. This is intended as an additional safety measure. Are you willing to cooperate with this if it proves necessary? *

Yes
No
Maybe
Not applicable

CYCLE & HORMONAL FACTORS

Some people notice that their hormonal cycle influences mood, sensitivity, energy, or the way emotions are experienced. I therefore ask a few optional questions below.

Do hormonal factors or cycles currently play a role in your mood, energy, or sensitivity?

Yes, menstrual cycle
Yes, perimenopause
Yes, menopause
Yes, other, namely:
No
Not applicable
I prefer not to say

Do you track your cycle

Yes
Sometimes
No
I no longer have a cycle
Not applicable

Are there moments in your cycle when you feel noticeably different emotionally or physically?

Do you experience PMS, PMDD, or other recurring hormonal complaints

LIFE CONTEXT

You do not need to provide extensive answers here. A few key words are sufficient.

Have you recently experienced important changes in your life? (e.g. work, relationship, family, health, or housing) * *

Are there intense events from your past that still have a significant impact on you? *

Are there losses or grief processes that still need attention? *

Are there important relationships in which there is currently tension, pain, or unspoken matters? *

LOGISTICS & INTEGRATION

Name of emergency contact (ICE) *

Phone number of emergency contact: *

Through which app may I reach you for a brief check-in the day after the session? *

WhatsApp
Signal
Viber
Sms

Do you have the option to be picked up by someone after the session? If so, by whom? *

Will there be someone you can turn to after the session to share your experience if you feel the need? *

Do you have sufficient time in the days after the session to rest and integrate? *

Yes
Probably yes
Probably not
I don't know yet

Do you have any food allergies or dietary requirements? *

Space for additional comments, questions, or information you consider important to share

May I use your email address to keep you informed of my activities, services, and future offers? *

Yes
No
I'm already on your mailing list

DECLARATION

I declare that I have completed this form truthfully and that I have not knowingly withheld any relevant medical or psychological information *

Yes

Send me a copy

Intake & Screening

for truffle sessions

Before you begin

MEDICAL SCREENING

CYCLE & HORMONAL FACTORS

LIFE CONTEXT

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