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Sacred Medicine Health Screening (PP)

All Information is Confidential
We care deeply about your safety and wellbeing as you consider working with earth medicines, whether in ceremony, private sessions, or microdosing protocols. The sacred medicines we work with - psilocybin mushrooms and others - are powerful allies that have guided spiritual seekers for thousands of years. They can facilitate profound healing and divine connection, but they're not to be taken lightly.

These experiences can range from subtle shifts in awareness to intense, transformative journeys. Some health conditions make participation risky - things like serious heart problems, uncontrolled high blood pressure, epilepsy, or conditions like bipolar disorder or schizophrenia. We're not doctors, but we've learned through experience that certain combinations just aren't safe.

Your honesty here is everything. We can't keep you safe if we don't know what we're working with. Sometimes we'll recommend you talk with Benjamin Malcom, our psychiatric pharmacist, especially if you're on multiple medications or have complex health issues. You can learn more about Ben HERE.

If you're unsure about anything, please talk with us. Part of our job is helping people discern whether this work is right for them at this time in their lives, and what approach might serve them best. That conversation itself is part of the sacred preparation. If you have specific questions, please contact Vanessa directly for a 15-minute touch base to discuss eligiblity to participate.

BOTTOM LINE: CHECK WITH YOUR DOCTOR IF YOU HAVE ANY HEALTH CONCERNS BEFORE PARTICIPATING.

ACKNOWLEDGEMENT
I acknowledge that I am choosing to participate in sacred medicine experiences held by Vanessa Crites, Vanessa Crites Consulting LLC and team. I agree to answer all the questions below honestly and that I must complete this form before being formally accepted as a participant/client. I agree to provide all the requested medical information regarding my mental and physical health. I agree to provide any updated information on my health up to the date of the ceremony/retreat/microdosing container. For ongoing services including microdosing protocols, I agree to promptly inform Vanessa Crites of any significant changes to my physical or mental health, medications, or life circumstances that may affect my participation. I understand that based on the information provided in this form, ongoing health updates, and any other relevant information, I may be excluded from participation if Vanessa Crites, Vanessa Crites Consulting, LLC deem that it may not be safe for me to participate in the selected experience.
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PERSONAL INFORMATION
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EMERGENCY CONTACT
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If you are registering for a Group Retreat, please list the dates below:
Please list any dietary restrictions, allergies and preferences you have for the retreat.
Are you new to psilocybin or psychedelic medicine? If not, please list the medicines you have worked with in the past along with a brief history of frequency and description of past experiences. *

STATEMENT OF RESPONSIBILITY
I understand that Vanessa Crites, Vanessa Crites Consulting LLC, does not provide mental health or medical services. Any statements provided have not been evaluated by the Food and Drug Administration. Any supplements I choose to consume in or outside of sessions are not intended to diagnose, treat, cure, or prevent any disease.
I understand and agree that it is my sole responsibility to consult with a qualified healthcare professional regarding the application, use, health, safety, and/or effectiveness of any supplement or other herbal/botanical products or information and instructions pertaining thereto.
If I choose to consume psychedelics, I acknowledge that I am choosing to do so as a personal choice, from my own free will, not based on any recommendation from any outside party including Vanessa Crites or Vanessa Crites Consulting, LLC. I take ownership and full responsibility for the choices I am making for my body, my physical and mental health, and my life.
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Sacred Medicine Health Screening (PP)

ACKNOWLEDGEMENT

PERSONAL INFORMATION

EMERGENCY CONTACT

MEDICAL HISTORY

STATEMENT OF RESPONSIBILITY