Safety Profile Questionnaire
By completing this questionnaire you can conclusively asses your safety profile for consuming psychoactive substances under the conditions of good set and setting. Screening participants before psychedelic experiences is a critical step to ensure participant safety. This questionnaire is based on the same standards for participant safety for psychedelic clinical trials conducted by the reputable institutions of MAPS, Johns Hopkins, and University of London. Since the year 2000, every participant in these trials was required to undergo the exact same standard of screening to ensure their safety for consuming high doses psychedelic substances for these trials. Of the 3000 plus participants engaged in these trials, there have been a total of zero patients that experienced any kind of physical or psychological harm occasioned by their respective psychedelic experiences. Zero.
For your safety, we ask that you answer each and every question truthfully. And that if you do find you are going to be at risk for consuming psychedelic substances that you do not engage yourself in their use whatsoever; even for therapeutic purposes.
When you submit this form, I will personally asses your answers and send you an email in a day or two with the result for your safety profile. Its completely free and for you to have have the assurance that you can work with psychedelics, even at heroic doses safely for therapeutic purposes provided you do them in a responsible set and setting and ideally with a trained guide that can look out for you during the experience.
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Personal Information
Full Name
*
First Name
Last Name
What is your age?
*
Email
*
example@example.com
Whatsapp Number
What is you Gender?
*
Male
Female
Prefer not to say
Are you currently pregnant or planning to become pregnant in the near future?
Yes
No
You should not take psychedelics when you are pregnant.
How did you hear about SoulSessions?
Poster
Recommendation
Workshop
Other
Please Specify how you heard about SoulSessions
Are you currently considering to explore taking psychedelics in a safe and responsible way, for purposes of healing, self-discovery, positive transformation and/or out of mere curiosity?
Yes
No
Please share some of the main reasons that you find yourself curious to explore the responsible use of psychedelic medicines.
Please specify why you are interested in completing this safety profile concerning the consumption of psychedelic substances.
How are you currently considering to explore taking psychedelics exactly?
Doing a guided Session/Sessions With SoulSessions by Lucien
Doing it with another Facilitator
Doing it by myself or with friends indoors
Doing it by myself or with friends in nature
Doing it by myself or with friends at a party
Other
What Kinds of psychedelic medicines are you most interested in working with? Select all that apply.
Psilocybin "magic" mushrooms
LSD
Mescaline (Wachuma, San Pedro)
DMT (Ayahuasca Brew)
DMT (N,N DMT smoked)
DMT (5 Meo, Toad venom Smoked)
Other
Please specify.
Are you currently located in Pai, Thailand?
*
Yes
No
Please specify until which date you plan to remain in Pai.
Where are you currently located and are you considering to visit Pai to experience SoulSessions? If so, Please specify your approximate dates to visit Pai.
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Overall Health
Are you quite healthy in general?
Yes
No
Please provide more detail so I can have a better idea of your general level of physical health and vitality.
Do you suffer from any kind of physical injuries, illnesses, diseases of any conditions that affect your physical health and/or vitality?
Yes
No
Please provide more detail that you suspect may be relevant.
Are you reliably getting sufficient exercise, sleep, quality socializing and affection?
Yes
No
Please provide more detail that you suspect may be relevant.
Substance use
Do you consume nicotine in any form?
Yes
No
Please specify
Do you smoke tobacco products (eg. cigarettes, vaping)?
Yes
No
Please specify what you smoke and how often eg; Occasional Smoker, Regular smoker Chronic Smoker and whether or not you are desiring to quit and wether or not you tried to quite in the past.
Do you consume alcohol?
Yes
No
Please specify how often and wether or not you are just getting tipsy or heavily intoxicated.
Do you consume other substances that are commonly associated with dependency like Opiodes (like oxycodone, hydrocodone, and morphine, heroin), Benzodiazepines (like Xanax, Valium, Ativan), and or Stimulants (like Adderall, Ritalin, cocaine and methamphetamine).
Yes
No
Please specify
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Prior experience with Psychedelics and expanded states of consciousness
Have you ever taken psychedelics before?
Yes
No
Please provide more information about your prior experience/ experiences and additionally share whether this experience/experiences were in some way therapeutic or helpful to you in your life.
Can you recall ever having an expanded state of consciousness experience by "natural" means? These can typically be occasioned in a multitude of ways without substances such as intense breathe work, meditation, fasting or extreme exertion.
Yes
No
Please provide more information about this prior experience/experiences.
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Safety Profile Questionnaire
Are you aware that, although taking psychedelics by no means causes schizophrenia, but it can certainly trigger an episode for those who already have a predisposition to schizophrenia and that therefore these people should not consider taking psychedelic substances under any circumstances?
*
Yes, I knew that already.
No, but now I do.
Do you have any reason to suspect that you are at risk for Schizophrenia, Bipolar Disorder or any other mental health conditions that may increase the risk of adverse effects or complications?
*
Yes
No
Please provide additional information that you feel may be relevant.
To the best of your knowledge, has any first or second degree relatives of yours (Siblings, Parents, Grandparents, Cousins) ever suffered from or been diagnosed with Schizophrenia, mania ?
*
Yes
No
Please provide more details.
Do you have any reason to suspect that you are at risk for any neurological disorders such as epilepsy or other seizure disorders that may increase the risk of adverse effects or complications?
*
Yes
No
Please provide additional information that you feel may be relevant.
Are you aware that SSRI medication will affect your tolerance to psychedelic substances and that you will likely require a higher dose than usual to feel the effects?
*
Yes, I knew that already.
No, but now I do.
Are you currently taking any SSRI medications?
*
Yes
No
Please list the SSRI you are taking and the dose.
Are you aware that medications that taking medications that contain an MAOI (MONOAMINE OXIDASE INHIBITOR) will significantly increase the subjective effects of taking a psychedelic and that it is strongly advised to discontinue these medications in the days before a session with psychedelics?
*
Yes, I knew that already.
No, but now I do.
Are you currently taking any medication that contains an (MONOAMINE OXIDASE INHIBITOR) MAOI? The four most commonly prescribed MAOIs are selegiline, isocarboxazid, phenelzine, and tranylcypromine
*
Yes
No
Please list any MAOI medications that you are currently taking and specify the dose.
Are you aware that taking psychedelics at a time in your life where you are really struggling to cope in general can potentially hinder rather than help you? And that the "best" time to work with psychedelics is actually when we are in a transitionary or grace period in life rather than at our lowest low?
*
Yes, I knew that already.
No, but I do now.
Are you currently experiencing an especially challenging period in your life right now? Some examples may be: going through a challenging transitionary period like breakup/divorce, change of career path, burnout/crisis, etc)
*
Yes
No, I'm doing pretty good these days.
Please provide more details.
Are you aware that, although taking psychedelics can certainly help and potentially heal the root cause of many mood disorders like depression and anxiety, it is still not a good idea to work with them when you find yourself in the depths of despair from these pathologies but rather to wait a few weeks for the dust to settle so to speak?
*
Yes, I knew that already.
No, but I do now.
Are you currently suffering from any of the following mood conditions (select all that apply):
*
None
Major Depressive Disorder (MDD)
Seasonal Affective Disorder (SAD)
Anxiety Disoder
Bipolar Disorder
PTSD
Other
Please provide additional details on any mood conditions you may be suffering with.
Are you currently suffering from any disorders that you suspect with be relevant to to your safety for taking psychedelics?:
Yes
No
Please provide any details you suspect may be relevant.
Do you have any allergies?
Yes
Not that I'm aware of.
Please list them.
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Preparation Protocols
Are you aware that it is necessary to follow certain lifestyle protocols for at least three days before and after an experience with psychedelics so that you in the right physical and mental condition to reap benefit from such an experience?
Yes, I knew that already.
No, But now I do.
Are you aware that, in the case that one plans to consume psilocybin "magic" mushrooms, one needs to take particular care to avoid the consumption of cannabis as part of the preperatory protocols for three days before, as well as during the experience and also for least three days after the experience?
Yes, I knew that already.
No, but now I do.
Are you aware that you can get access to all the preperation, journey and integration protocols for FREE under the SoulSessions "Resources" tab?
Yes, I knew that already.
No, but now I do.
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Almost done! You Just click submit and I'll send you an email in a day or two giving you the result of your safety profile. If you get the all clear, you can be 100% sure that you can take even heroic doses of psychedelics at no risk to your physical or psychological wellbeing.
Submit
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