PARTICIPANT - Communication, Consent and Release

Communication, Consent and Release

PARTICIPANT
"Participant" refers to the person receiving, or potentially receiving, psilocybin.

INSTRUCTIONS:

If you (participant) have completed this form within the past year, you may skip it and close out.

If you are NOT SURE, or have NOT completed this form within the past year, please complete it. This form is required to complete an intake and consultation.

Additionally, if you'd like to update your Release of Information (who you give permission to conduct or receive consult information about you), filling out the second page of this form will override any prior Releases.

If you have any questions, please email info@psychedelicinteraction.com

Thank you!
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email to send a copy of this agreement:*
Please review carefully. Note you will be emailed a copy; however you may also download a copy from here.
Authorized Signature - I affirm that I am capable of providing informed consent for a consultation. By signing below, I confirm that I have read, understood, and agreed to the terms in the document. I release Dr. Speer and PharmD Consult, LLC from any liability resulting from communications through these platforms, and I agree to proceed with full understanding of the associated risks. I understand that I am voluntarily engaging in a consultative service that is educational in nature, outside the scope of HIPAA, and does not replace medical care or provider oversight. *

Clear

Release of Information
If a center, facilitator, provider or someone else is ordering or conducting my consult:

I permit the following named centers, facilitators, providers or authorized individuals/entites to conduct a consultation about, for or on me. I understand this involves sharing written and/or verbal information about my health history, medications and personalized assessment/recommendations, limited to the minimum information necessary to serve the consultation purpose. This also means they will receive a copy of my written consult unless they choose not to. I understand I can revoke or update this permission at any time by re-submitting this form, or by emailing info@psychedelicinteraction.com.
Name, email and phone of permitted center, facilitator, provider or authorized individual/entity who may conduct a consult on me and receive a copy of my written consult (if none, please state 'none'):*
Please be sure to enter full names, emails and phone numbers. If not appliable, skip this question. If none, please state 'none'.
If a center, facilitator, provider or authorized individual/entity is ordering or conducting your consult, would you like to receive a copy of your written consult?*
If I am purchasing or conducting my own consult:

I understand I will receive a copy of my written consult by default.

I additionally permit the following individuals or entities to receive a copy of my written consultation upon their request to PharmD Consult by emailing info@psychedelicinteraction.com. (No need to add any individuals or entities you’ve already listed above). I understand I can revoke or update this permission at any time by re-submitting this form, or by emailing info@psychedelicinteraction.com.
Name, email and phone of permitted individuals or entities who may receive a copy of my written consult upon their request (if none, please state 'none'):
Please be sure to enter full names, emails and phone numbers. If not appliable, skip this question. If none, please state 'none'.
Authorized Signature*

Clear
Please verify that you are human*
Should be Empty:

Communication, Consent and Release

Release of Information