Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Health Information *

Do you have any physical health conditions that may effect your therapy?

Yes

No

Are you currently taking any prescription medications? *

Yes

No

Have you been diagnosed with any mental health conditions *

e.g. anxiety, depression, PTSD, Bipolar

Yes

No

Experience with Psychedelics *

e.g. Psilocybin, LSD, MDMA, Ketamine

Yes

No

Consent and Acknowledgements *

Please review and check each box to indicate your agreement

I understand that psychedelic assisted therapy is an exploratory process aimed at supporting personal growth, healing and self-discovery.

I acknowledge that this therapy is not a substitute for traditional medical treatment and that I have shared my health information accurately and honestly.

I understand that while all information provided is kept confidential, there are legal and safety limits to confidentiality.

I consent to the use of my information for therapy and assessment purposes and understand I may withdraw my consent at any time.