The Alchemy of Serenity, LLC - Psychedelic Safety Assessment

Psychedelic Safety Assessment

Center for Medicinal Mindfulness & The Alchemy of Serenity, LLC

Taking this assessment is required before participating in any psychedelic related events or services with The Alchemy of Serenity, LLC, credentialed by the Center for Medicinal Mindfulness. The questionnaire could be used as a self- assessment, or may also be part of a structured psychedelic safety interview to participate in ongoing classes or psychedelic therapy. Please return before your scheduled session or interview and contact your facilitator with any questions.

A Few Notes About the Assessment:

Psychedelic experiences are very safe, but they are not for everyone. None of the questions, except the first one about pregnancy, will automatically disqualify you from participating in psychedelic events at The Alchemy of Serenity, LLC, credentialed by the Center for Medicinal Mindfulness. This is an opportunity to discuss safety and help your facilitator create the necessary preparation and integration support so they can provide the safest and most appropriate container for your experience. Participation agreements and informed consent documents may also be required to participate in any psychedelic medicine programs with The Alchemy of Serenity, LLC, credentialed by the Center for Medicinal Mindfulness. Although most experiences are positive and deeply meaningful, psychedelics often show us what we need to see, not what we always want to see. Therefore, being approved to participate in an experience does not guarantee an easy or enjoyable experience. Contraindications (reasons not to participate in a psychedelic experience) are included in the specific service's participation agreement and listed throughout these questions. With the right support, private individual sessions or small groups can be facilitated to treat significant clinical concerns that might not be as safe to engage in a large group setting or celebratory experiences.

If you have ANY concerns whatsoever about your physical or mental health we have a doctor on staff who specializes in making this kind of assessment that you can speak to. If you have any concerns about your mental health. and your capacity to participate in any event safely. we have licensed mental health practitioners that can support you in your decision making process as well.

To members of BIPOC, LGBTQ+ and other marginalized communities who experience trauma caused by generational systems of oppression, none of these questions are intended to exclude you because of the ongoing traumas of racism and other forms of discrimination that you commonly face. Comments are provided under some of the questions to provide additional context about why certain questions are asked.

If you have any questions regarding your personal safety or this assessment, you can email us at safecommunity@medicinalmindfulness.org.

Again, our 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. All information provided is confidential and stored in a HIPAA protected drive or secure filing system.

Name*

Age*

Email*

Please use the same email you used on other forms

Phone #*

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Email

Relationship to you*

Physical Safety

1. Are you pregnant or nursing?

YesNoMaybe

2. Do you have any food allergies, or are you sensitive to incense or essential oils? (Please note: At the end of the session snacks may be provided to participants that usually include orange juice. chocolate (sometimes with nuts), gluten-free pretzels. and strawberries or grapes. You are responsible for informing the Facilitator(s) of any severe food allergies before the experience begins, and to take responsibility for any snacks you consume)

YesNo

If Yes, Please Describe

3. 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.

YesNoMaybe

If Yes or Maybe, Please Describe

4. Do you have any past or present concerns around suicide or self-harm?

YesNo

If Yes, Please Describe

5. Are you currently on any medications, supplements or recreational drugs that could affect you safely participating in a psychedelic experience?

YesNoMaybe

If Yes or Maybe, Please Describe

6. Do you have a safe home environment and a generally stable residence. and are not subject to active or ongoing domestic violence? (Please note: Homelessness and not having a safe space to return to after an experience may not provide the necessary setting for proper integration)

YesNo

If No, Please Describe

7. Are you currently employed, a student, or otherwise financially stable?

YesNo

If No, Please Describe

Psychological Safety

8. Do you have a history of traumatic or difficult life events that have not been addressed or are not being supported therapeutically? (Please note: The Center for Medicinal Mindfulness specializes in the treatment of trauma and PTSD. Severe, unprocessed trauma may indicate a need to start in a clinically supported setting, not in celebratory spaces. BIPOC, LGBTQ+ and members of other marginalized communities who may experience ongoing traumas from discrimination are strongly encouraged to attend celebratory events. Addressing systemic traumas such as ones caused by generational systems of oppression is a primary focus of the Center for Medicinal Mindfulness.)

YesNo

If Yes, Please Describe

9. Have you ever required significant treatment or been hospitalized for a psychological or emotional disorder or for any psychological or emotional reason?

YesNo

If Yes, Please Describe

10. Have you ever dealt with a pattern of unstable relationships that caused you significant distress?

YesNo

If Yes, Please Describe

11. Do you have a history of disruptive or violent physical, sexual, or emotional behavior?

YesNo

If Yes, Please Describe

12. Have you ever had extremely unusual or disconcerting thoughts or ideas, or extreme levels of energy (inability to sleep for days or racing thoughts, or alternatively extremely low energy) at any time. or after the effects of a psychedelic or cannabis should have worn off?

YesNo

If Yes, Please Describe

13. Have you ever seen or heard things or people that weren't there at any time or after the effects of a psychedelic or cannabis should have worn off?

YesNo

If Yes, Please Describe

14. Have you ever obsessed over an idea, conspiracy, or belief in a way that has caused difficulties in your life?

YesNo

If Yes, Please Describe

15. Do you ever feel extremely uncomfortable or anxious in group transformational processes? (Please note: We recognize that BIPOC community members may feel uncomfortable in predominantly white spaces. This question is more about feeling unsafe in ANY group process because of significant social anxiety. Acute social anxiety may reduce your ability to relax in an inner personal journey experience and may indicate a need to start in an individual, clinical setting that provides additional support and privacy. You have a right to feel safe. Please let us know if you don't.)

YesNo

If Yes, Please Describe

16. Have you recently had a major transformational experience, with a psychedelic medicine or otherwise, that feels almost complete but not quite, or unresolved? (Please note: It has been our experience that this may mean you are primed for a transformational breakthrough so please increase your self care regiment and your personal support network.)

YesNo

If Yes, Please Describe

Psychedelic Safety

17. Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines physically, emotionally or otherwise?

YesNo

If Yes, Please Describe

18. Has a trusted health professional ever advised you to cease or otherwise limit consumption of cannabis, psychedelic medicines, or using altered states practices?

YesNo

If Yes, Please Describe

19. Have you ever experienced extreme paranoia or anxiety, panic attacks, or other extreme negative experiences while using cannabis, any psychedelic medicines, or during any other time in your life that required a significant intervention? (Please note: paranoia, anxiety and panic are not uncommon under the influence of a psychedelic. Our team knows how to support these experiences safely, however, it is very helpful to know beforehand if this has happened in the past or is a common experience for you.)

YesNo

If Yes, Please Describe

20. Have you ever fainted or blacked out or otherwise adversely lost consciousness while on cannabis or any psychedelic medicine?

YesNo

If Yes, Please Describe

21. Do you have any acute, current or past (within the last 2 years) substance abuse/dependence issues?

YesNo

If Yes, Please Describe

22. As you contemplate attending this experience, or when checking in with yourself right before it begins, are you extremely anxious?

YesNo

If Yes, Please Describe

23. Have you ever been or are you currently involved in any legal proceedings? Criminal or civil? (Please note: Due to societal misunderstandings about psychedelics and cannabis, it may not be safe to participate in our program if you are involved in any legal proceedings. Please speak with your facilitator about this before deciding to attend.)

YesNo

If Yes, Please Describe

24. Anything else you think we should know about? Use the space to include any additional comments, questions, or concerns.

I certify that this information is accurate and complete. I understand that I can schedule appointments to speak to a medical doctor and/or a licensed mental health counselor about my Psychedelic Safety Assessment. I understand that an additional safety evaluation is required for clinical services and events, and if I choose to participate in non-clinical, training. or celebratory events. I affirm that I am healthy enough to do so.

Name

Signature

Date