Interbeing Fungi Consultation Form

Before moving forward, it’s important to know that current research does not back medicinal mushrooms as a safe and effective mental health treatment if you've ever been diagnosed with schizophrenia, bipolar 1, had manic episodes, or are presently on lithium. We can not, in good faith, recommend our medicine to you if you are of this population. If you feel like an exception should be made, please first talk to your primary care provider, and then afterwards send us an email at team@interbeingfungi.com*

I have read the statement above, understand the risks, and feel safe to proceed.I should pause and talk to my PCP before continuing.

Please confirm that you are over the age of 21*

Yes, I am over 21 and feel safe to proceedNo, I am not 21

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Instagram Username

@yourinstagram

How do you prefer we contact you with information ?*

EmailTextMessage through the Signal appPhone call

Do you identify as any of the following?

Black, Indigenous or a Person of Color (BIPOC)LGBTQIA2+ or QueerFormerly incarcerated for non-violent offensesLow income / using SNAP or Medicaid

How did you hear about us?*

Please Specify*

The more specific you are, the safer we feel! e.g. my friend Julio, or the Boulder Farmer's Market, etc.

Medical Info : *

Do you currently take any supplements or prescription medication? If so, please list each one with duration of use.

On average, how sensitive are you to other medicinal substances like coffee, alcohol, cannabis, etc?*

Not sensitive at all (high tolerance)Moderately sensitive (average tolerance)Very sensitive (low tolerance)

Can you tell us about your previous experience with psychedelics?*

Interbeing Fungi Consultation Form

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