New Client Consultation Registration

Reserve Your Personal Consultation

Discuss your psilocybin options with one of our experienced staff on a 25 minute call. Please complete this brief application to book your free consultation.
Name*

First NameLast Name
Email*
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Preferred Pronouns*

They/them/theirShe/her/hersHe/him/hisOther
Phone Number*
Please enter a valid phone number.
Date of Birth (must be 21 or older)*

MonthDayYear
Date
How did you find out about us?
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Where do you currently live?*

Street Address

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Emergency Contact Name, Phone Number & Relation*
Experience Questionnaire

Please take a moment to answer these questions about your reasons for exploring psychedelics. Your answers will allow our staff to better assist you during your consultation call. You will schedule your consultation call on the following page.
Please describe the reasons you are seeking a psilocybin experience: *
Are there specific areas of personal growth, spiritual exploration, creativity enhancement, or therapeutic purposes that interest you?*
Do you have any experience with psilocybin or other psychedelics, whether recreational or therapeutic?*

YesNo
Do you have experience with non-ordinary states of consciousness such as those induced by meditation, breathwork, or hypnosis?*

YesNo
If YES to either of the last two questions, briefly describe your prior experience(s):*
On a scale of 1-10, how prepared do you feel to undertake a psilocybin journey? (It's okay to feel unprepared, we are here to educate and support you on your journey). *
Please briefly explain your selection:*
Do you feel any of the following are barriers to you accessing psilocybin services? (select all that apply)?*

AvailabilityCostTime and scheduleCurrent mental health concernsCurrent support systems in place (or not in place)Limited knowledge and experience of psychedelicsLegal concernsJudgement from family and peersNo concernsOther
Please briefly elaborate on any barriers you selected:*
Mental Health and Medical History

These questions will help our staff best align you with an appropriate program and the most qualified licensed facilitator.
In the past, have you ever participated in mental health therapy or counseling?*

YesNo
Currently (now), are you participating in mental health therapy or counseling?*

YesNo
In the past, have you ever participated in an outpatient mental health program, other than traditional counseling?*

YesNo
Currently (now), are you participating in an outpatient mental health program, other than traditional counseling?*

YesNo
In the past, have you ever received mental health care for any of the following complaints? (select all that apply)*

DepressionAnxietyPost traumatic stress disorderAcute stressObsessive compulsive disorderBipolar disorderSchizophreniaOther psychosisEating disorderNever received mental health care for any of these complaintsOther
Currently (now), are you receiving mental health care for any of the following complaints? (select all that apply)*

DepressionAnxietyPost traumatic stress disorderAcute stressObsessive compulsive disorderBipolar disorderSchizophreniaOther psychosisEating disorderNever received mental health care for any of these complaintsOther
Please briefly describe your selection(s):*
Do you have a family history of psychotic disorders?*

YesNo
If YES, please list your relationship to this family member (e.g., mother, brother, daughter, etc.) and briefly explain the nature of the psychotic disorder:*
Have you ever been hospitalized for a mental health issue?*

YesNo
If YES, please briefly describe your hospitalization:*
Are you having thoughts of causing harm, or wanting to cause harm, to self or others?*

YesNo
Do you have a history of causing harm, or wanting to cause harm, to self or others?*

YesNo
Do you feel you currently have adequate mental health support systems in place? This may include such things as a therapist or counselor, community group or spiritual community, friends, family, etc.*

YesNo
If YES, please briefly describe those support systems. If NO, please briefly describe what support systems might be helpful.*
Currently (now), do you take any medications for any reason?*

YesNo
If YES, please list any current medications, dosage, and reasons:*
In the past, have you taken any medications for mental health concerns/issues?*

YesNo
If YES, please list medications, dosage, and reasons:*
Have you taken lithium in the past 30 days?*

YesNo
Are you currently pregnant?*

YesNoN/A (male)
Are you currently breastfeeding?*

YesNo
Do you have a history of uncontrolled blood pressure or heart disease?*

YesNo
Additional Information
Have you ever served in the Armed Forces?*

YesNo
Are you interested in a private session or being part of a group session?*

PrivateGroupUnsure or no preference
The benefits of psilocybin are best realized by participants with a strong support system, such as family, friends, community, religion, or mental health providers. Do you feel adequately supported or would you be interested in receiving information on additional resources?
Do you have any specific comments, concerns or questions that you would like to address during our consultation call?
Anything else you’d like us to know before your call?
List of Drop Thesis Licensed Facilitators
Are there particular Drop Thesis facilitators your are interested in working with (you can select multiple)? You can click the link above to learn more about our facilitators!*

Erin NaftalinRyan ReidRiver JenkinsJP CroweLindsey ReinhartFrank LarsonCheri PlantenbergI'd like some help deciding!No preference
For you consultation call, do you have a preference for meeting virtually online or in-person at the service center?*
The service center is located at 505 NW Franklin Ave, Bend, OR 97703
Hit "SCHEDULE" below to book your consult on the next page.
Privacy and Sharing of Information

By submitting this form, I authorize the service and its associated facilitators to collect my personal and service related information. In addition, I authorize the service center and its associated facilitators to communicate with a referring organization or individual as deemed necessary for my beneficial treatment. I also understand that my personal and service related information information is confidential and will only be disclosed to third parties with my permission.
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Reserve Your Personal Consultation

Experience Questionnaire

Mental Health and Medical History

Additional Information