The Golden Channel Inquiry Form

THE GOLDEN CHANNEL - INQUIRY FORM
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Please list any medical conditions: *
Please list all medications and supplements you are currently taking. Include: name, dose frequency, how long you have been taking them (ex: Lipitor, 20 mg, 1xdaily, for 2 years. Vitamin C, 500mg 1xdaily, 5 years, etc.)*
I have a personal history of (select all that apply)

Personal history of seizures?Personal history of psychosis or psychotic break?Personal history of mania or manic episode?Personal history of panic attack?Personal history of panic disorder?Personal history of paranoia?Personal history of suicidal ideation?Personal history of suicide attempt?Family history of psychosis or psychotic break?Family history of mania or manic episode?None of these apply to me.
What is your intention for joining The Golden Channel microdosing + coaching program?*
Have you ever microdosed before?*

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If you have microdosed before, please tell us about your experience:*
Which plant medicine properties most speak to you at this time?*

Empathogen: heart-opening, increase compassion, empathy, emotional & social connectionEntheogen: elevate consciousness, enhanced mood, focus, creativity, clarity, presenceBlend: elevated mood, emotional balance, increased sense of calm, positive outlook, opennessI am not sure and need guidance (option to set up a private consult with Dr. Stefanie is below)
Please share a bit about your current wellness practices and routine:*
Please share a bit about your religious or spiritual beliefs & practices. If you do not have one, you can write N/A:*
On a scale from 1-10, how committed are you to making your wellness a priority?*
How did you learn about us?*
If you have been referred to us, please tell us (by name) who referred you:
Anything else you feel is important for us to know:
Please upload a copy of your driver's license or other form of ID. We need this for proof of age over 25 years old (JPG or JPEG only)*

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Your signature here is attesting to the above information being correct and your agreement to the following terms: http://bit.ly/4nf7gHb *

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Secure your spot in The Golden Channel by making your deposit below. NOTE: PayPal & credit card payments will incur a 3% fee (which will show up as "tax"). Payment via Venmo has no charge. To pay with Venmo, use: @TheSacredHouse Please write "TGC Deposit" in the memo section of your payment. If Venmo asks for the last 4 digits of the phone number associated with the account, use 9936.
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The Golden Channel Deposit/Month 1Your deposit will go toward your Golden Channel membership, covering your entire 1st month. If for any reason, we determine that The Golden Channel is not a match for you, we will refund your deposit immediately. You can make your deposit via Venmo @TheSacredHouse or using the PayPal option below. Please write "TGC Deposit" in the memo section of your payment. If Venmo asks for the last 4 digits of the phone number associated with the account, use 9936.
$333.00

25-minute Private Consultation with Dr. StefanieWe highly recommend you set up a 25-minute Private Consultation with Dr. Stefanie to discuss each of the 3 medicine options, to go over intentions. and to have an opportunity to ask any questions you may have. This will help ensure you select the best option for you and your 4-month protocol is off to the perfect start!
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THE GOLDEN CHANNEL - INQUIRY FORM