Bendable Therapy Psilocybin Wellness Program Screening Application Logo

  • Bendable Therapy Psilocybin Wellness Program Screening Application

  • Screening Application Information:

    Hello and welcome to the Bendable Therapy Psilocybin Wellness Program screening application. Completing this application is the first step to beginning our program. Please see the figure below for an overview of what the Bendable Psilocybin Wellness Program looks like. When filling this application, please be as complete as possible in your responses and take the time needed to answer all questions. Congratulations on taking the first step of your psilocybin journey!
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  • For additional details on our Psilocbyin Wellness Program, please refer to this program overview.


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  • Demographic Information

  • Psilocybin Preparedness

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  • Mental Health History

  • Medical History

  • Additional Information

  • WHO-5 Well-Being Index

    The World Health Organization-Five Well-Being Index (WHO-5) is a short self-reported measure of current mental wellbeing. Your responses to this questionnaire will not influence the outcome of your application with Bendable Therapy. Please answer the following 5 statement:

  • Patient Health Questionnaire (PHQ-8)

    This short 8-question questionnaire asks about symptoms and experiences of depression. It is not meant to diagnose or treat you with depression, but rather to help us better understand the well-being and mood of those seeking psilocybin services through Bendable Therapy. Your responses to this questionnaire will not influence the outcome of your application with Bendable Therapy.

  • General Anxiety Disorder-7 (GAD-7) Questionnaire

    This final 7-question questionnaire asks about symptoms and experiences of anxiety. It is not meant to diagnose or treat you with anxiety, but rather to help us better understand the well-being of those seeking psilocybin services through Bendable Therapy. Your responses to this questionnaire will not influence the outcome of your application with Bendable Therapy.

  • Bendable Privacy and Information Sharing Policy

    At Bendable, we believe in transparency and integrity in our dealings with our clients. Please read this Privacy and Information Sharing Policy so you can understand how we use and share the information you provide to Bendable, beginning with our Screening Process and continuing through your engagement with Bendable. The Screening Process includes the Screening Application, Screening Interview, and Screening Team discussions.

    Types of Information:

    Personal identifying information is information that can distinguish or identify you as an individual, such as your name and contact information. Personal de-identified information is information about you that does not contain any of your identifying information. Aggregated information is information that is derived from personal de-identified information but is summarized to provide mathematical totals, like total clients served, demographic make-up of clients, and other such numerical results.

    Bendable’s Use of Your Information:

    At Bendable, we will only use your personal identifying information when needed to carry out our normal and necessary business operations including serving you, our client. We will only share your personal identifying information and de-identified personal information with those we work with to run Bendable (our business partners). These include but are not limited to:

    1. Licensed service centers and licensed facilitators that we engage directly in your care process. These entities and individuals will be involved in your psilocybin journey and will need information such your medical and mental health history to provide you with the most comprehensive and best-suited care possible.
    2. Software and other technology providers, including our client records software vendor, Google Gmail and other such tools, and researchers, practitioners or other collaborators we partner with to improve client outcomes and safety.

    Other than these, we will not share your personal identifying information with any other entities or individuals unless required by law, nor will we sell or otherwise share your personally identifiable information or de-identified information without your written consent.

    We use your individual de-identified information along with all other clients to formulate aggregated information and we use and share this information to measure our effectiveness, improve our services, collaborate with community and research partners, and report to our funders and other stakeholders. For example, we would use aggregated information in a report stating how many total people have sought services through Bendable and for what reasons to measure the efficacy of our services and help us continually advance our ongoing mission of providing evidence-based therapies for health and well-being.

    Your Rights:

    You have the right to:

    1. Ask questions or seek clarifications about this policy or our information practices at any point now or in the future at portal@bendabletherapy.org.
    2. Refuse to share your personal identifying or de-identified information with Bendable. To do so, simply do not provide such information to Bendable and do not submit this Screening Application. Refusing consent to share this information with Bendable means you will be unable to access Bendable’s services.

  • Thank you for completing the Bendable Therapy Psilocybin Wellness Program
    application. We will be in touch. Take good care.

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