Sacred Mushroom Journey 9/23

We are so excited to share this ceremony space with you!

We want to get some basic information to make sure that we are providing the most safe and supportive experience for you. All of the info on this form will be kept confidential.

We will have a 20 minute intake call on the phone once you've completed this form to connect and get to know one another.

Full Name*

First NameLast Name

What is your age?*

Contact Number*

Email Address*

example@example.com

What drew you to this experience? What motivation/intention do you bring?*

Have you had psychedelic experiences before?*

YesNo

If so, please describe what psychedelics you've experienced, how often, and at what dosages.*

Were these previous experiences helpful and considered positive? Or not helpful? Please explain.*

Do you have any medical conditions or injuries? Please list them here.*

Please list any current medications by name that you are taking.*

Please list any current homeopathic/Ayurvedic/Chinese medicine remedies by name that you are taking.*

Please list any current supplements by name that you are taking.*

How sensitive are you to things like caffeine, over the counter pain medication, and cough syrup?

Have you ever fainted?*

YesNo

Do you or anyone in your family have a history of epilepsy or seizures?*

YesNo

Are there any needs you have for ceremony (physical or otherwise) that we need to be aware of?*

Please give a thorough mental health overview, including traumas or issues you are currently working through.*

Have you seen or are you currently seeing a therapist or personal coach?*

YesNo

What spiritual practices do you engage with and how do these practices support you?*

Is there anything else you would like us to know that has not been addressed in this form?*

Are you thinking of staying the night at Elevation Central after ceremony? Shared rooms (2 single beds per room) are $150 per room ($75 per person) with limited spaces available.*

YesNo

Do you have any food allergies (especially chocolate since the mushrooms may be served in the form of chocolates) that we need to know about?*

Private Sacred Mushroom Journey