Psychedelic Experience Intake Form
The questions in this section will gather some basic information about you
Thank you for your interest in a guided psilocybin healing experience.This application helps us understand your intentions, history, and readiness for this work. All responses are kept strictly confidential and are used only to ensure a safe and aligned experience.Please note: We currently offer legal psilocybin journeys in Colorado, and provide preparation and integration support in California for those who cannot travel.
Section 1: Basic Info
Name
First Name
Last Name
E-mail
*
example@example.com
Phone Number
Please enter a valid phone number.
Section 2: Logistics + Location
Where are you located?
Are you able to travel to Colorado for a legal psilocybin experience?
Yes
No
Maybe / Unsure
Section 3: Your Interest & Intentions
What draws you to this work at this time?
What are you hoping to heal, explore, or understand through this experience?
Have you worked with psychedelics before?
Yes, with guidance
Yes, solo
No, this will be my first time
Section 4: Health & Safety Screening
This section is designed to protect your wellbeing. Please answer honestly and thoroughly.
Do you currently take any psychiatric medications? Please list. (e.g., SSRI's, antipsychotics, mood stabilizers)
Do you have a personal or family history of any of the following?
Bipolar disorder
Schizophrenia or other psychotic disorders
PTSD
None of the above
Have you experienced any major emotional trauma in the past year? If so, please describe:
Do you have any current medical conditions we should be aware of? If so, please describe:
Section 5: Support System
Are you currently working with a therapist, coach, and/or support group? If so, please describe:
Do you feel you have a support system (friends, family, and/or community)? If so, please describe:
Section 6: Readiness & Consent
How ready do you feel to participate in this work? Use scale 1-10, 1 = I am unsure if I am ready and 10 = I am absolutely ready!
Is there anything else you'd like to mention?
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Submit
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