• Bendable Psilocybin Program Application

  • Screening Application Information:

    Hello and welcome to the Bendable Therapy Psilocybin Wellness Program screening application. Completing this application is the first step to beginning our program. Please see the figure below for an overview of what the Bendable Psilocybin Wellness Program looks like. When filling this application, please be as complete as possible in your responses and take the time needed to answer all questions. Congratulations on taking the first step of your psilocybin journey!
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  • For additional details on our Psilocbyin Wellness Program, please refer to this program overview.


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  • Format: (000) 000-0000.
  • Preferred pronouns:*
  • Sex:*
  • Do you currently live at this home address?*
  • Format: (000) 000-0000.
  • How did you hear about Bendable?*

  • Psilocybin Intentions and Readiness

  • Do you have any experience with psilocybin or other psychedelics, whether recreational or therapeutic?*
  • Do you have experience with non-ordinary states of consciousness such as those induced by meditation, breathwork, or hypnosis?*
  • Do you feel any of the following are barriers to you accessing psilocybin services? (select all that apply)*

  • Mental Health Questions

    Current Conditions
  • Currently (now), are you participating in mental health therapy or counseling?*
  • Currently (now), are you participating in an outpatient mental health program, other than traditional counseling?*
  • Currently (now), are you receiving mental health care for any of the following complaints? (select all that apply)*
  • Are you currently having or recently had thoughts of causing harm, or wanting to cause harm, to self or others, including suicide?*
  • Do you feel you currently have adequate mental health support systems in place? This may include such things as a therapist or counselor, community group or spiritual community, friends, family, etc.*

  • Mental Health Questions

    Past Conditions
  • In the past, have you ever participated in mental health therapy or counseling?*
  • Have you ever participated in an ACT or DBT program or counseling?*
  • In the past, have you ever participated in an outpatient mental health program, other than traditional counseling?*
  • In the past, have you ever received mental health care for any of the following complaints? (select all that apply)*
  • Do you have a history of causing harm, or wanting to cause harm, to self or others, including suicide?*
  • Do you have a family history of psychotic disorders?*
  • Have you ever been hospitalized for a mental health issue?*

  • Medical Questions

    Current conditions
  • Currently (now), do you take any medications for any reason?*
  • Have you taken lithium in the past 30 days?*
  • Are you currently pregnant?*
  • Are you currently breastfeeding?*

  • Medical Questions

    Past conditions
  • In the past, have you taken any medications for mental health concerns/issues?*
  • Do you have a history of uncontrolled blood pressure or heart disease?*

  • Additional Information

  • Which program(s) are you interested in?*
  • Do you require financial assistance to participate in the the program? Please note that our scholarship funds are limited and based on donor and community contributions.*
  • Have you ever served in the Armed Forces?*

  • Optional Demographic Information

    This information is voluntary but supports our ability to communicate and develop access and equity programs.
  • Which race(s) best describes you? (select all that apply)
  • Gender: How do you identify?
  • What is your birth sex?
  • What is the highest level of education you have completed?
  • What is your current employment status?
  • What is your total HOUSEHOLD income per year?

  • Bendable Privacy and Information Sharing Policy

    At Bendable, we value transparency and integrity. This policy explains how we collect, use, and share your information—starting with your Screening Application and continuing throughout your engagement with us.

    Types of Information:

    • Personal identifying information: e.g., your name and contact details.
    • De-identified information: details about you without identifying data.
    • Aggregated information: summarized, anonymized data (e.g., total clients served).

    Howe We Use and Share Information:

    We use your personal identifying information only to support your care and operate Bendable. We may share it with:

    1. Licensed service centers and facilitators involved in your care.
    2. Technology providers and collaborators who help us deliver and improve services.

    We do not sell your data or share it beyond these purposes unless legally required or with your written consent.

    De-identified and aggregated information helps us measure impact, improve care, and report to partners and funders.

    Your Rights:

    You have the right to:

    1. Ask questions or seek clarifications about this policy or our information practices at any point now or in the future at contact@bendabletherapy.org.
    2. You may refuse to share information by not completing the Screening Application. Doing so means you won’t be able to access Bendable’s services.

  • Thank you for completing the Bendable Therapy Psilocybin Wellness Program application. We will be in touch. Take good care.

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