SSS Application
As Spirit Leads...
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Check the conditions that apply to you:
Chronic Pain
Cancer
Anxiety
Diabetes
Depression
Psychiatric disorder
Epilepsy
Other
Are you currently taking any medication?
Yes
No
Please list them.
If on Anti-depressant, Psilocybin is Used in Place of Ayahuasca
Do you have any medication allergies?
Yes
No
Not Sure
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
If there is anything significant you would like to tell us about, please do so here. If you have any questions, please ask them here.
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
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