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All Information is Confidential
INFORMATION ABOUT PSILOCYBIN SESSIONS

Psilocybin microdosing and macro sessions are intended to be a personal growth experience and should not be considered a substitute for psychotherapy, but rather a complimentary therapeutic aid. Working with psilocybin can involve intense experiences accompanied by physical and emotional releases. It is not recommended for people with cardiovascular diagnoses, serious hypertension, epilepsy, or psychiatric conditions such as bi-polar disorder, schizophrenia, or multiple personality disorder, recent fractures or surgeries, acute infectious disease, or spiritual emergencies. There is no data on the safety of psilocybin in women that are pregnant. If you have any doubt as to whether you should participate, it is encouraged that you speak with the organizer/facilitator of the session, along with consulting a doctor or therapist.

IMPORTANT: PLEASE CONSULT YOUR DOCTOR FOR ANY CONCERNS ON MEDICATIONS AND HEALTH ISSUES PRIOR TO PARTICIPATING.

In cases where there are medical issues, psychiatric diagnosis, or the participant is taking multiple pharmaceuticals, a consultation with Benjamin Malcom, a board-certified psychiatric pharmacist that provides psychopharmacology consulting for safe and beneficial psychedelic experiences, may be required for medical clearance before proceeding. You can learn more about Ben here.

Your honesty is critical and ensures your safety.

ACKNOWLEDGEMENT
I acknowledge that I am choosing to participate in sacred medicine experiences held by Vanessa Crites, Vanessa Crites Consulting LLC and team. I agree to answer all the questions below honestly and that I must complete this form before being formally accepted as a participant. I agree to provide all the requested medical information regarding my mental and physical health. I agree to provide any updated information on my health up to the date of the ceremony retreat. I understand that based on the information provided in this form, and on the updated information, I may be excluded from participation in the requested ceremony retreat Vanessa Crites, Vanessa Crites Consulting, LLC deem that it may not be safe for me to participate in the selected experience.
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PERSONAL INFORMATION
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EMERGENCY CONTACT
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Is your Emergency Contact informed that you are attending a ceremony/retreat?*
For Retreat Participants: Is your emergency contact at the retreat with you?*

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Please list any dietary restrictions, allergies and preferences you have for the retreat.
Are you new to psilocybin or psychedelic medicine? If not, please list the medicines you have worked with in the past along with a brief history of frequency and description of past experiences. *

STATEMENT OF RESPONSIBILITY
I understand that Vanessa Crites, Vanessa Crites Consulting LLC, does not provide mental health or medical services. Any statements provided have not been evaluated by the Food and Drug Administration. Any supplements I choose to consume in or outside of sessions are not intended to diagnose, treat, cure, or prevent any disease.
I understand and agree that it is my sole responsibility to consult with a qualified healthcare professional regarding the application, use, health, safety, and/or effectiveness of any supplement or other herbal/botanical products or information and instructions pertaining thereto.
If I choose to consume psychedelics, I acknowledge that I am choosing to do so as a personal choice, from my own free will, not based on any recommendation from any outside party including Vanessa Crites or Vanessa Crites Consulting, LLC. I take ownership and full responsibility for the choices I am making for my body, my physical and mental health, and my life.
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INTAKE FORM

ACKNOWLEDGEMENT

PERSONAL INFORMATION

EMERGENCY CONTACT

MEDICAL HISTORY

STATEMENT OF RESPONSIBILITY