Sacred Mushroom Journey 9/23

Microdosing with the 5 Elements

with Jason and Claudia
We are so excited to share this sacred container 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 go over the application.
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 microdosed psilocybin before?*

YesNo
If so, please describe your microdosing experience (how often, for how long, what dosage, etc).*
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 supplements/homeopathic/Ayurvedic/Chinese medicine remedies by name that you are taking.*
Do you or anyone in your family have a history of epilepsy or seizures?*

YesNo
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?*
Should be Empty:

Microdosing with the 5 Elements