The Psychedelic Screener Mastermind
Program Interest and Application Form
Name
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First Name
Last Name
Best Email for Program Communications and Updates
*
example@example.com
Which of the following describes you? (select all that apply)
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I have an advanced medical degree or practice as a healthcare professional (e.g. MD, DO, PharmD, PA, NP etc)
I am a mental health professional although do not have an advanced medical degree (e.g. therapist, psychologist, social worker)
I am currently part of the Spirit Pharmacist Member Resource and Support Program
I currently or have worked to support screening persons for psychedelic use
None of the above describe me
Describe yourself and why you want to join this program?
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Do you currently work in the 'psychedelic field'? Describe your experience in the field. Feel free to include links to websites or other background information supporting your answer. If you do not currently work in the psychedelic field, describe any future plans you have to.
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I understand that attendance to over 50% of the live small group mastermind sessions is required to receive the program certificate and I know I will have the availability every other Thursday evening 5-6:30pm CT starting March 12th to participate:
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Yes, I'm available Thursday evenings
No, I'm not available Thursday evenings
I'm not sure if I'm available at those times
I understand that the Psychedelic Screener Mastermind Program is aimed at increasing confidence and skills relating to screening applications for psychedelic use and that this is not a 'psychedelic facilitator training' or program that otherwise aims to train persons to administer psychedelics
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Yes, I understand the program is about psychedelic screening
Seriously?! I thought it a training program to facilitate psychedelics
I agree that if I was admitted to the program that I would act respectfully towards other participants, hold their names and any other information they may share in confidence, and generally do not mind sharing my own name, professional background, and experiences within the closed container of the program.
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Yes, I could agree to all that
No, I'm not able to agree to this
I have reviewed the program syllabus and agree to the policy regarding program enrollment, refunds, expected behavior, and requirements to receive my certificate of completion
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I have read through it and happily agree
I read through it but have some concerns
I've not read through it
I understand that enrollment in the program provides me with access to the Psychedelic Pharmacology Master Series. I have reviewed and agree with the terms and conditions of course ownership found here https://www.spiritpharmacist.com/course-contract
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I have read through it and happily agree
I read through it but have some concerns
I've not read through it
Is there anything else you would like to communicate about your application to participate in the Psychedelic Screener Mastermind Program or questions about the program you currently have?
How did you hear about the Psychedelic Screener Mastermind? (please write in a name if referred or told by someone)
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