Criterion 5: Eligibility documentation

This criterion opens Core Function II, Intake. Screening asked who is appropriate and eligible. Intake is the administrative act of bringing an eligible person formally into the program, and it begins with the record. Criterion 5 is where the judgments made in Criteria 1 through 3 stop living in the facilitator's head and become a durable, transferable document.

Learning Objectives

By the end of this module, the trainee will be able to:

• State the function of intake documentation and distinguish it from the screening decisions it records.
• Name the categories of information an eligibility-and-appropriateness record must capture, and trace each back to the screening criterion that produced it.
• Distinguish eligibility from appropriateness, and document why a specific program is the right container for a specific person rather than only that the person is admissible.
• Explain why standardized forms reduce omission and bias, and identify what standardization does and does not solve.
• Describe the continuity-of-care function of documentation across a multidisciplinary team, and the specific failures that poor records produce.
• Identify the confidentiality and records-security obligations that govern intake documentation, and connect them to the legal and ethical framework of Criterion 4.
• Recognize that no single universal documentation standard exists in this field, and reason from the primary frameworks that do exist rather than from an invented one.
• Produce a complete, defensible intake record and audit an existing one for gaps.

Key Terms

Intake. The administrative and initial-assessment procedures by which an eligible person formally joins a program. Intake formalizes what screening determined; it is the threshold between applicant and participant.

Eligibility documentation. The written record establishing that a person met the program's admission criteria, including the readiness findings (Criterion 1), the coexisting-conditions review (Criterion 2), and the integrated eligibility decision (Criterion 3), with the reasoning that connects them.

Appropriateness. The match between a specific person's goals and needs and a specific program's focus, design, and capacity. A person can be eligible for psychedelic work in general and not appropriate for a given program, a distinction carried forward from Criterion 3.

Continuity of care. The consistent transfer of accurate client information across everyone involved in a person's care, so that a facilitator, medical clinician, and integration provider all work from the same record rather than from separate partial impressions.

Standardized intake form. A fixed-structure document used with every client to capture the same categories of information in the same way, which reduces omission and inconsistency between clients and between staff.

Multidisciplinary team. The set of providers, which may include a facilitator, a prescriber or physician, a psychotherapist, and an integration provider, whose coordinated work depends on a shared and accurate record.

Confidentiality. The obligation to protect what a client discloses. In documentation this extends to how records are stored, who may access them, and how they are transmitted, governed by health-information law where applicable and by professional ethics everywhere (see Criterion 4).

Records security. The operational safeguards, physical and electronic, that keep intake records accessible to authorized providers and protected from unauthorized access, consistent with the confidentiality obligation.

Audit trail. The property of a record that lets a later reader reconstruct what was decided, on what basis, and by whom. An eligibility decision that cannot be reconstructed from the record has not been adequately documented.

Core Teaching

What intake documentation is for

A screening decision that exists only in the facilitator's memory is not a completed decision. Criterion 5 is the point where the readiness read, the coexisting-conditions review, and the eligibility determination become a written record that outlives the conversation that produced them. The record does three things at once. It provides continuity of care, so that everyone who later touches the person's care works from the same information. It provides accountability, so that the basis for admission can be reconstructed and defended. And it provides legal protection, so that the program can demonstrate that eligibility was determined responsibly rather than casually. None of this is clerical. Documentation is the mechanism by which a program's judgment becomes transferable, auditable, and durable.

The unusual feature of this criterion, relative to the four before it, is that its subject matter is not pharmacological. There is no receptor here. The discipline is instead procedural and ethical, drawn from health-information law, professional codes, and clinical-documentation practice. That does not make it less consequential. Many of the worst outcomes in any clinical field trace not to a wrong decision but to a correct decision that was never recorded, or recorded so poorly that the next provider could not use it. This module treats documentation as the load-bearing infrastructure it is, and it is honest that the field has no single codified standard, so the reasoning matters more than any template.

What the record must capture

An eligibility-and-appropriateness record is built from the outputs of the screening criteria, assembled in one place with the reasoning intact. Four categories are essential, and each traces back to a specific earlier criterion, which is why intake cannot be done well by a facilitator who skipped or rushed the screen.

The first category is readiness. The record should capture the psychological, social, and physiological findings from Criterion 1, not as a checkbox but with enough substance that a later reader understands the person's stability, support, and physical suitability. The second is coexisting conditions. The medical, psychiatric, and pharmacological findings from Criterion 2 belong in the record, including the medication review and any referrals or clearances obtained, because these are precisely the details a downstream medical provider will need and precisely the details whose omission is dangerous. The third is the eligibility decision itself, from Criterion 3: the integrated determination, whether admit, admit with conditions, defer, or refer, together with the reasoning that connects the domains and any conditions attached. The fourth is appropriateness, addressed below, which is the category most often left out.

The test for whether these are adequately documented is the audit-trail test. A competent colleague, reading the record cold, should be able to reconstruct what was decided, on what basis, and by whom. If the record supports only the conclusion and not the reasoning, it has failed the test, because a conclusion without its basis cannot be evaluated, corrected, or defended.

Eligibility and appropriateness are not the same

The criterion names two things, eligibility and appropriateness, and they are distinct. Eligibility is whether the person may be admitted at all, which the screening criteria settled. Appropriateness is whether this particular program is the right container for this particular person, which is a matching question rather than a safety threshold. The distinction was introduced in Criterion 3 as client-level eligibility versus program-level fit; here it becomes a documentation requirement. The record should state not only that the person qualifies but why this program suits their goals and needs.

The reason to document appropriateness explicitly is that its absence is a common and quiet failure. Programs differ in focus. A trauma-informed clinical program, an addiction-recovery program, and a non-therapeutic spiritual circle are different containers with different capacities, and a person well suited to one may be poorly served by another. A person seeking relief from post-traumatic stress may be an excellent fit for a trauma-informed program and a poor fit for a spiritually oriented circle that offers no clinical support, even though the same person is eligible for psychedelic work in the abstract. Documenting the appropriateness rationale forces the match to be examined rather than assumed, and it creates a record that a later reader can use to understand why the person was placed where they were.

Standardization: what it solves and what it does not

Standardized intake forms exist because unstructured intake produces two predictable failures: omission, where a facilitator forgets to ask something because nothing prompted them, and inconsistency, where different clients or different staff generate non-comparable records. A fixed-structure form that captures the same categories the same way for every client addresses both. It ensures the medication review is always taken, the readiness domains are always recorded, and the appropriateness rationale is always stated, rather than depending on whether a given facilitator happened to remember. Standardization is the same discipline that Criterion 3 identified in the clinical trials, where inclusion and exclusion criteria are specified in advance and applied consistently to make decisions auditable rather than arbitrary.

Standardization has limits. A form guarantees that a question is asked; it does not guarantee that the answer is accurate, that the facilitator understood it, or that the judgment built on it was sound. A person can under-report medications on a well-designed form, as the live serotonin-toxicity vignette in Criterion 2 illustrated. Standardization reduces the failures of omission and inconsistency; it does not replace clinical judgment, rapport that elicits honest disclosure, or the verification steps that catch a dangerous gap. A program that treats a completed form as proof of a sound intake has confused the record for the reasoning.

Continuity of care and the multidisciplinary team

Psychedelic programs frequently involve more than one provider. A facilitator holds the sessions, a prescriber or physician may manage a medication question raised in Criterion 2, a psychotherapist may provide ongoing support, and an integration provider may carry the work forward across the weeks after dosing. The preclinical plasticity findings discussed in Criterion 1 do not establish the duration of a corresponding window in humans. Each of these people needs the same accurate picture of the client, and the record is what gives it to them. When documentation is good, a medical provider seeing the person for a cardiac clearance already knows the compound, the plan, and the relevant history. When documentation is poor, each provider reconstructs a partial picture from scratch, details are lost between handoffs, and the person is asked to repeat disclosures they already made, which erodes both safety and trust.

The specific failures of poor continuity are worth naming because they are concrete rather than abstract. A medication flagged during screening but not carried into the record can reach the dosing day unaddressed. A deferral condition set in Criterion 3, for example a required washout, can be lost if it is not documented and tracked, so that the person is admitted before the condition is met. An appropriateness concern noted by one provider can fail to reach the person actually running the session. Each of these is a documentation failure with a clinical consequence, and each is preventable by a record that travels intact.

Confidentiality and records security

Intake documentation collects sensitive information, including medical and psychiatric histories, medication lists, and personal circumstances. The obligation to protect it is not separate from the obligation to collect it. The confidentiality and records-security duties introduced in Criterion 4 apply directly here. In clinical settings governed by health-information law, records must be stored and transmitted in compliance with that law; in all settings, the professional duty to protect client disclosures governs how records are kept, who may access them, and how they move between providers. The practical requirements are secure storage against unauthorized access, an access policy that limits records to those who need them for the person's care, and a transmission practice that does not expose sensitive information when records move between team members. A program that collects thorough intake information and then stores it carelessly has created new harm in the course of trying to prevent others.

The consent to share information among the team is itself a documentation item. Where a facilitator intends to coordinate with a prescriber, a therapist, or an integration provider, the client's informed authorization for that specific sharing should be obtained and recorded, which connects directly to the informed-consent work of Criterion 6. The ethics literature on consent in psychedelic care emphasizes that consent must be genuine and specific rather than a blanket formality (Lee, Rosenbaum, & Buchman, 2024), and consent to share records is one concrete instance of that principle.

The absence of a universal standard, and how to reason without one

A facilitator looking for the single authoritative documentation standard for psychedelic intake will not find one, because the field does not yet have codified, universally adopted documentation requirements the way established clinical professions do. What exists instead is a set of partial frameworks that a competent program reasons from. The state-regulated-access programs impose documentation requirements on licensed practice, for example, the preparation, administration, and integration structure that Oregon and Colorado require, which generates records at each stage. The clinical trials generate rigorous documentation under their protocols and oversight. Health-information law governs records in clinical settings. Professional ethics codes govern conduct across settings. The research-safety guidance in the field, developed for human hallucinogen studies, models the level of care the work warrants (Johnson, Richards, & Griffiths, 2008).

The honest position is that a program must construct its own documentation standard by reasoning from these frameworks and the requirements of its own jurisdiction, rather than adopting a standard that does not exist. This is the same discipline Criterion 4 required for law and Criterion 3 required for eligibility criteria: write the standard down in advance, ground it where possible in a stated reason, and apply it consistently. A facilitator should be candid, including with themselves, that a template downloaded from an unverified source is not a standard, and that the adequacy of a record is judged by whether it captures the reasoning and serves continuity, not by whether a form was filled in.

Documentation as the first act of the therapeutic relationship

Intake is administrative, and it is also the first concrete experience the person has of the program's values. A thorough, respectful, unhurried intake communicates that the program is careful and that the person is seen. A rushed or careless intake communicates the opposite, and it does so at the moment the person is deciding how much to trust the container they are entering. This is not a reason to sacrifice rigor for warmth; the two are compatible, and the most reassuring intake is one that is both careful and humane. It is a reason to recognize that the record-keeping of this criterion is not separate from the relational work of the ones that follow. Documentation done well protects the person, coordinates their care, and tells them, in the first hour, what kind of program they have joined. This criterion hands directly to Criterion 6, where the confidentiality and consent agreements gestured at here become formal signed instruments.

Clinical and Decision Tools

Tool 1. Intake record contents map

Each row is a required category of the eligibility-and-appropriateness record, traced to the criterion that produces it. Use this to assemble a complete record and to audit an existing one for gaps.

Tool 2. Eligibility versus appropriateness

Document both. Eligibility is a safety-and-suitability threshold; appropriateness is a match between person and program. A person can clear one and not the other.

Tool 3. Intake documentation checklist

Confirm each element is present and adequate. Shaded items are the omissions with the most direct safety consequences; treat an unchecked shaded item as a stop before admission.

Tool 4. Documentation failure modes and their consequences

Each failure below is a documentation error with a downstream clinical or legal effect. The point is that poor records cause harm actively, not only passively.

Worked Example: A Completed Intake Record

The following models the reasoning and structure this criterion should produce. Details are fictional. The record is written so a colleague reading it cold could reconstruct the decision.

Client identifier: R.M. | Date: intake completed [date] | Evaluator: [facilitator] | Program: medically supervised psilocybin clinical program | Compound: psilocybin.

Readiness (Criterion 1): Psychological: major depressive disorder, recurrent, treatment-resistant; stable in weekly therapy two years; good distress tolerance and documented prior integration; no current suicidality; no personal or family history of psychotic or bipolar disorder. Social: supportive informed spouse; stable housing and work; treating therapist available for integration across the plasticity window. Physiological: no cardiac history; blood pressure normal on two readings. All domains read Proceed.

Coexisting conditions (Criterion 2): Medication review: tapering off an SSRI under psychiatric supervision; agreed washout before dosing; no other interacting agents; no lithium, tramadol, or QT-prolonging drugs. Depression is an indication, not an exclusion. Referral: coordinating with prescriber for washout confirmation.

Eligibility decision (Criterion 3): Admit with conditions. Single condition: prescriber-confirmed completion of the SSRI washout and a stable baseline. Marker: written confirmation from prescriber. Condition recorded here and flagged for tracking; person is not to be scheduled for dosing until it is met.

Appropriateness: This program is a medically supervised clinical setting with prescriber coordination and integration support, which matches this person's treatment-resistant depression, active medication management, and need for continuity of care. A non-clinical retreat would not suit the medication coordination this case requires. Appropriateness confirmed for this program specifically.

Consent to share: Client has authorized coordination with the named prescriber and treating therapist; signed authorization on file (see Criterion 6). No other sharing authorized.

Records: Stored in the program's secure clinical record system; access limited to the care team; washout-condition tracker set with a review date.

Case Vignettes

Work each vignette by identifying the documentation problem, its downstream consequence, and the corrective. Fillable response sheets are in the companion worksheet PDF.

Vignette A

A facilitator conducts a thorough verbal screening and forms a sound eligibility decision, but records only the conclusion, admit, in a single line, with none of the readiness or coexisting-condition findings. Two weeks later a covering colleague must run the preparation session.

Guided questions: What does the covering colleague not know, and why does it matter? Which test does this record fail? What specifically should have been documented, and what is the risk created by its absence?

Vignette B

During screening, a client discloses a medication that requires a prescriber-coordinated washout, and the facilitator sets this as a deferral condition. The condition is discussed but never written into the intake record. Scheduling staff, seeing an admit decision, book the dosing session.

Guided questions: Which documentation failure occurred, and what is its direct clinical consequence? How does this connect to the pharmacology taught in Criterion 2? What documentation practice would have prevented the person from being scheduled prematurely?

Vignette C

A person seeking help for post-traumatic stress is admitted to a spiritually oriented, non-therapeutic circle. The intake record documents eligibility thoroughly but says nothing about why this program fits this person. During the work, it becomes clear the person needed clinical trauma support the program does not provide.

Guided questions: Which required record category was omitted? Distinguish the eligibility question from the appropriateness question in this case. How would documenting the appropriateness rationale have surfaced the mismatch before admission?

Vignette D

A program collects detailed intake records, including full psychiatric and medication histories, and stores them in an unsecured shared folder accessible to all staff and several unrelated contractors.

Guided questions: What obligation from Criterion 4 is being violated? Is thorough collection sufficient if storage is careless? What specific records-security practices does this situation require, and what harm has already been created?

Vignette E

A facilitator intends to coordinate a client's care with the client's outside therapist and prescriber, and begins sharing the intake record with them, without having obtained or recorded the client's authorization to do so.

Guided questions: What documentation and consent step was skipped? Why is consent to share a specific item rather than a blanket assumption? How does this connect to the informed-consent work of Criterion 6, and what should the facilitator have done first?

Role-Play and Practice Scripts

Practice in pairs, then switch. The aim is to conduct intake documentation in a way that is thorough and legally sound while remaining humane, since intake is the person's first concrete experience of the program.

Framing the documentation process for the client

“The next part is paperwork, and I want to explain why it matters rather than just handing you forms. What we record here is how everyone involved in your care stays on the same page, and how we make sure nothing important gets lost between now and your session. I will go through it with you, and you can ask about anything.”

Taking the medication history for the record

“I am going to write down every medication and supplement you take, by exact name, including anything occasional. If you are not certain of a name, we will confirm it together before this record is complete, because the specific drug is what determines whether something is safe. This goes into your record so the medical side of your care has it too.” Practice recording precisely and confirming rather than approximating.

Obtaining consent to share among the team

“I would like to coordinate with your prescriber and your therapist so your care is consistent. That means sharing parts of this record with them. I need your written authorization to do that, and you can decide exactly who is included. Nothing gets shared beyond what you authorize.” Practice treating consent to share as a specific, recorded permission.

Documenting the appropriateness rationale aloud

“Let me tell you why I think this program specifically fits what you are looking for, and I will record this reasoning. You came for support with trauma, and this is a trauma-informed program with clinical support and integration. That match is part of why I am comfortable admitting you here rather than referring you elsewhere.” Practice stating and recording the match, not just the eligibility.

Self-Assessment and Reflection

Knowledge check

1. State the three functions intake documentation serves and explain why a decision held only in memory is incomplete.
2. Name the required record categories and trace each to the screening criterion that produces it.
3. Distinguish eligibility from appropriateness and explain why appropriateness must be documented explicitly.
4. Explain what standardized forms solve and two things they do not solve.
5. Give two specific documentation failures and the downstream clinical consequence of each.
6. State the audit-trail test and explain how to tell whether a record passes it.
7. Explain why no single universal documentation standard exists here and how a program should reason without one.

Reflection

1. Audit one of your own recent intake records against the contents map. Which category is thinnest, and what would make it pass the audit-trail test?
2. Where in your current process could a deferral condition be set verbally and then lost? What documentation practice would close that gap?
3. How are your intake records stored, and who can access them? Does that access policy match your confidentiality obligation, or is there a gap to close?

Summary

Criterion 5 opens Intake by turning the screening judgments into a durable record. Its subject matter is procedural and ethical rather than pharmacological, and its stakes are real, because correct decisions that are never recorded, or recorded without their reasoning, fail the people they were meant to protect. The eligibility-and-appropriateness record assembles the readiness findings from Criterion 1, the coexisting-conditions review from Criterion 2, and the eligibility decision from Criterion 3, and it adds the appropriateness rationale that explains why this program fits this person, a category that is frequently and quietly omitted. Standardized forms reduce omission and inconsistency without replacing judgment or honest disclosure. The record's purpose is continuity of care across a multidisciplinary team, and its failures, a lost medication, an untracked deferral condition, a missing appropriateness rationale, are documentation errors with clinical consequences. Confidentiality and records-security obligations from Criterion 4 govern how the record is stored and shared, and consent to share is itself a recorded item. Because the field has no single universal documentation standard, a program must build its own by reasoning from the frameworks that exist and applying it consistently, judged always by whether the record captures the reasoning and serves continuity. This criterion hands directly to Criterion 6, where confidentiality and consent become formal signed agreements.

References

Johnson, M. W., Richards, W. A., & Griffiths, R. R. (2008). Human hallucinogen research: Guidelines for safety. Journal of Psychopharmacology, 22(6), 603–620. https://doi.org/10.1177/0269881108093587

Lee, A., Rosenbaum, D., & Buchman, D. Z. (2024). Informed consent to psychedelic-assisted psychotherapy: Ethical considerations. The Canadian Journal of Psychiatry, 69(5), 309–313. https://doi.org/10.1177/07067437231225937

Phelps, J. (2017). Developing guidelines and competencies for the training of psychedelic therapists. Journal of Humanistic Psychology, 57(5), 450–487. https://doi.org/10.1177/0022167817711304

Oregon Psilocybin Services Act, Measure 109 (2020), codified at ORS Chapter 475A. https://www.oregonlegislature.gov/bills_laws/ors/ors475A.html

Colorado Natural Medicine Health Act, Proposition 122 (2022), as amended by Senate Bill 23-290 (2023); C.R.S. § 12-170-101 et seq. https://leg.colorado.gov/bills/sb23-290

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code

Uses and disclosures for which an authorization is required, 45 C.F.R. § 164.508. https://www.law.cornell.edu/cfr/text/45/164.508