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Microdosing 30-Minute Consultation Intake Form

Thank you for your interest in scheduling a free 30-minute consultation to explore microdosing and our approach to healing. To make the most of our time together, please complete this form as thoroughly and honestly as you can. Your responses will help me understand your background, intentions, and any relevant health considerations, so I can offer you the most appropriate support and guidance during our call. This form is for informational and educational purposes only. It is not intended as medical advice, nor does it promote any illicit activity. Please know that your privacy is very important to us. All the information you share will be kept strictly confidential. Thank you for your time, your honesty, and your commitment to your own growth and well-being!
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    You must supply a working email address for consultation service
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    Please complete with phone number including area code
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    Please complete this field, including your ZIP/postal code
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    Please select all that apply and describe further in the next page of the form
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    Please select all that apply and describe further below. f you do not have any of the psychiatric conditions listed please select 'none of the above'.
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    Please use this space to give more Information on how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc.
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    Please include a complete list of your prescription medications including the drug NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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    Please select the option that most closely matches your use
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    Psilocybin mushrooms, LSD, ayahuasca, DMT, MDMA, ketamine, ibogaine, mescaline etc.
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    If you have not used any please mark 'none of the above'
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    If you’ve had any experiences with these medicines, please tell us how it went and whether it was for recreational, therapeutic, or shamanic use..
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    If you are a woman, are you currently pregnant or do you suspect you might be? Have you recently given birth? Are you breastfeeding?
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    Please use the space below to share any specific questions you may have about the program, as well as any other requests, concerns, or topics you’d like us to be aware of.
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    Thank you for taking the time to complete this form and for the trust you’ve placed in us. We deeply value your openness and your commitment to this process!
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