Today's Date
*
/
Month
/
Day
Year
Date
Facilitator Email
example@example.com
First and Last Name
*
Birth Date
*
/
Month
/
Day
Year
You must be at least 21 years old to participate.
Email
*
Service Center Name
*
Date of Journey
-
Month
-
Day
Year
Date
Emergency Contact First and Last Name
*
Emergency Contact Phone Number
*
Client Information Form.
*
The Oregon Health Authority requires some paperwork for legal psilocybin sessions, which this form auto-populates for your review and signature. Click "See PDF" below to see this paperwork at any time. The "Client Information Form" contains important health screening questions. Please confirm that you select "no" on all Client Information Form questions, with the exception of section (3)(b) which requires a response below. If your answer is "yes" to any other question beside (3)(b), unfortunately we are unable to serve you at this time.
Question (3)(b): Are you currently being treated by a medical, clinical, or other healthcare provider for a medical, mental health, or behavioral health condition?
*
Yes
No
During my administration session, I approve the following supportive touch:
*
Hugs
Placing hands on hands
Placing hands on feet
Placing hands on shoulders
I do not consent to any supportive touch during my session
Signature
*
To participate in a legal psilocybin experience, the Oregon Health Authority requires some paperwork. Your responses and signature have been automatically populated into the PDF below (click "see PDF" to see your responses). Please download and review the document thoroughly before signing. By signing above, the you acknowledge that this electronic signature is legally binding. You confirm having thoroughly reviewed all documents provided by the Oregon Health Authority, and all suggestions provided by Alex Kenyon, and agree to affix this single signature to each required document. The signer further acknowledges that Alex Kenyon, the provider of this form, shall be held harmless from any liability arising from the completion of these forms.
See PDF
Submit
Please verify that you are human
*
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