• Thank you

    We will go over these and any other questions you might have over zoom during our preparation call. Please book a 50 minute session with the link provided after you submit this form.

  • All Information collected on this form is kept confidential and is shared with no one outside of remix your world.

    Your honesty and vulnerability is greatly appreciated. It helps us know how to help you navigate your processes. We honor your privacy and the safety of your information. This record will NOT be duplicated or printed.

  • Taking this assessment is required before participating in any medicine related events or services with Remix Your World. The questions may also be part of a structured psychedelic safety assessment interview to participate in psychedelic sound journeys. Please return before your scheduled session and contact me with any questions.

    A Few Notes About the Assessment:

    Psychedelic experiences are very safe, but they are not for everyone. This assessment is for your own safety, nothing more. Please be honest with yourself and us. Answering “yes” to any of the safety questions below may indicate a need for additional support before participating in a medicine related experience. A “yes” answer does not automatically disqualify you from our services. It is an opportunity to discuss safety, and to help your facilitator create the necessary preparation and integration support, and the safest and most meaningful container for your experience.

    Although most experiences are positive and deeply meaningful, truthfully answering “no” to every question does not guarantee an easy or enjoyable experience. Although positive outcomes are common, exploring the material evoked by these medicines is sometimes difficult to do. Your facilitator is here to support you throughout the process.

    Contraindications [reasons not to participate in a medicine related experience] are included in the specific service’s participation agreement and listed in the questions. With the right support, private individual sessions or small groups can be facilitated to treat significant clinical concerns that might not be easiest to engage in a large group setting or training program. Speak to your facilitator if you have any questions.

    Again, these events are very safe, but they are not for everyone. Please be honest with yourself and us regarding your readiness for exploring psychedelic medicines. We are here to support you through this decision-making process.

  • What expereince are you participating in?
  •  -
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Biological Sex*

  • Gender Identity*

  • Relationship Status (Choose as many as apply)*
  • How would you describe your eyesight? (Check all that apply)*
  • How would you describe your hearing? (check all that apply)*
  • Do you have any past or present medical conditions (either physical or mental health) that may affect your ability to safely participate in this program? A psychedelic experience is not appropriate for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy.*
  • Have you ever had a severe, adverse reaction to using psychedelic medicines, physically, emotionally or otherwise?*
  • Have you ever experienced extreme paranoia, anxiety, panic attacks, or other extreme negative experiences while using any psychedelic medicines, or during any other time in your life that required a significant intervention?*
  • Have you ever had extremely unusual or disconcerting thoughts or ideas, or extreme levels of energy (inability to sleep well for days, racing thoughts, or alternatively extremely low energy) after the effects of a psychedelic should have worn off?*
  • Have you ever dealt with a pattern of unstable relationships that caused you significant distress?*
  • Have you ever obsessed over an idea or belief in a way that has caused difficulties in your life?*
  • Have you lost a loved one in combat?*
  • Have you ever been diagnosed as Autistic?*
  • Have you ever been diagnosed with ADD or ADHD:*
  • Have you ever had suicidal ideations or ideas of ending your own life?*
  • Have you ever attempted suicide?*
  • Have you ever assaulted anyone that you consider innocent?*
  • Are you a person who menstruates?*
  • Do you frequently experience?*

  • Do you drink alcohol?*
  • Have you ever been admitted to a rehab or detox facility for alcohol or substance use?*
  • Please Check any of the following substances that you have experienced one or more times in your life.*
  • Have you ever been:*
  • Are your biological parents alive?*
  • I felt safe as a child.*
  • When I was a child, neighbors or my friends’ parents seemed to like me.*
  • When I was a child, teachers, coaches, youth leaders were there to help me.*
  • Someone in my family cared about how I was doing in school.*
  • Which best describes your daily amount of sleep*
  • Do you normally feel well rested when you wake up?*
  • Do you look forward to sleep?*
  • Do you have a safe home environment and a stable residence?*
  • Are you currently employed and financially stable?*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: