Meadow Application .org

Full Name*

First NameLast Name
Your birthday (we only serve 21+)*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Age
What is your sex?*

MaleFemaleOther
What is your occupation?*
Email*
example@example.com
Phone Number*
Zip code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What inspired you to apply to our program?*
What inspired you to apply to our program? (Select the one that resonates most)*

I want to address anxiety, depression, and/or burnout.I’m seeking deeper self-understanding, clarity, or spiritual growth.I’ve experienced trauma and am ready to do deeper healing work.I’m struggling with chronic pain, illness, or physical distress.Other
If you believed this healing journey could have the impact you’re hoping for, how ready do you feel to begin? (Choose the option that feels most true for you)*

I feel deeply ready and committed to doing this work.I’m open and curious, but still feeling some hesitation.I know I want to heal, but I feel emotionally unsure or overwhelmed right now.Other
If you felt confident that this journey could help you, which of the following best describes your current financial ability to participate?*

I have the ability and feel ready to invest.I would need to use credit or a payment plan to make it work.I don’t currently have the financial means, but I’m deeply interested.Other
What has your healing and growth journey looked like?
What are you seeking in doing this work together?
Have you (or any first degree family) been diagnosed with bipolar, schizophrenia, or experience suicidal ideation?*

YesNo
Are you currently taking psychiatric medication (SSRI, SNRI, mood stabilizer, anxiolytic, etc)?*

YesNo
Are you currently taking a sleeping medication?*

YesNo
Are you currently using a substance more than once per week (alcohol, cannabis, etc)?*

YesNo
Are you open to weaning off of medications and/or substances in order to have a psilocybin experience?*

YesNoN/A
How did you hear about us?*

Google searchOregon Health Authority databaseYoutubeInstagramTwitter/XFacebookPodcastTherapist/ClinicianFamily/friend
I understand that after I click submit on this form, I will be redirected to schedule a consultation call on the next page.*

Yes
Unfortunately we are unable to serve you at this time. Feel free to explore other legal service centers licensed by the Oregon Health Authority at this link.
Should be Empty: