F.I.V.E X University College London
5-MeO-DMT EEG Research Study Application
What's Included:
Thank you for considering to be a volunteer for our upcoming research study, please fill out the form below truthfully and in its entirety to be considered for the study. Those who are selected will be provided with accommodations for 2 nights/3 days at the Tandava retreat center in Tepoztlan, Mexico with meals provided as well as pre and post integration support. Airfare is not included. Potential applicants will be sent a more thorough screening form.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Todays Date
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Month
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Day
Year
Date
Birthdate
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Month
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Day
Year
Date
Age
Amount of times you have sat with 5-MeO-DMT
What other psychedelics have you sat with and how many times?
Have you sat still or relatively still each time you have sat with 5-MeO-DMT?
Have you ever had a challenging 5-MeO-DMT experience? Please explain in detail.
Have you ever had a challenging integration period after 5-MeO-DMT or any other psychedelic?
Is your desire to participate in the research study explorative, or more for healing?
Which of the following best reflects your home life?
stable, supportive and healthy
challenging at the moment
unstable and unhealthy
Are you currently in therapy? Please explain why and for how long?
Are you currently on any medications?
Are you suffering from depression, PTSD or anxiety?
Have you ever received a mental health diagnosis of any type?
Do you suffer from chronic pain and/or central nervous system disease?
I swear that I have answered the above answers truthfully and to the best of my ability
Yes
No
Signature
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