ATMA-CENA PreScreen

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

What college are you registered with?

5

Please fill in your license number:

6

Please enter your date of birth:YYYY-MM-DD

Date

7

What was your assigned sex at birth?

Male

Female

8

Are you presently pregnant, planning to become pregnant or presently breastfeeding?

YESNO

10

Please list other:

11

I am willing to remain on birth control or use another adequate from of birth control through the study period of at least 10 days after psilocybin session and take pregnancy tests to confirm I am not pregnant before psilocybin is administered.

YESNO