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*
Format: (000) 000-0000.
Zip code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What inspired you to apply to our program?*
What is your primary reason for seeking support at this time?*

Reducing my anxiety, depression, and/or burnout.Finding my purpose, clarity, or spiritual growth.Deeper healing from traumatic experiences.Relief from chronic pain, illness, or physical distress.
Have you ever had any of the following medical conditions?*

DementiaSeizure disorderActive cancer treatmentStroke (in last 6 months)Aortic or brain aneurysmHeart attack (in last 6 months)Unstable angina or heart failureNone of the above
Are you currently taking any of the following psychiatric medications?*

Daily Benzodiazepine (Xanax, Ativan, Klonopin, etc)Nightly sleep meds (Trazodone, Ambien, Lunesta, etc)Tricyclic antidepressant (amitriptyline, nortriptyline, clomipramine, etc)Mood stabilizer (Lithium, Depakote, Lamictal, Tegretol, etc)Antipsychotic (Seroquel, Abilify, Risperdal, Zyprexa, etc)MAOI (Phenelzine, Tranylcypromine, Selegiline, etc)None of the above
Have you ever been diagnosed with any of the following?*

Bipolar IPsychosis or hallucinationsBorderline personality disorderSchizophrenia or schizoaffective disorderNone of the above
Have you ever experienced mania, psychosis, a recent suicide attempt, or are you currently experiencing suicidal thoughts?*

YesNo
Do any first-degree relatives (parents, siblings, children) have schizophrenia or a serious psychotic disorder?*

YesNoNot sure
What has your healing and growth journey looked like?
What are you seeking in doing this work together?
Have you ever been diagnosed or hospitalized with: schizophrenia, schizoaffective disorder, mania, borderline personality disorder, or suicidal ideation?*

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

YesNo
Do you want to taper off of your medications?*

Yes, it’s a goal of mineI’m open to it, if necessaryNo, I’m content staying on themI haven’t really thought about it
Are you currently using a substance more than once per week (alcohol, cannabis, etc)?*

YesNo
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.
Which of the following best describes your current financial ability to invest in your mental health?*

I have the ability and feel ready to invest if it's a fit.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 curious.
Are you willing and able to travel to Portland, Oregon for an in-person psilocybin session?*

Yes, I can travelNo, I cannot travel to Portland
Best case scenario, how would using psilocybin improve your life?*
How did you hear about us?*

Google searchOregon Health Authority databaseYoutubeInstagramTwitter/XFacebookTikTokPodcastTherapist/ClinicianFamily/friend
Who was it that told you about Meadow? We'd like to thank them!
I understand that after I click submit on this form, I will be redirected to schedule a discovery 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.
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