Emerald Valley Holistic Client Eligibility Form

Intake Eligibility Form

OHA Licensed Psilocybin Service Center -1267 W 7th Ave Eugene Oregon
This form helps us determine whether psilocybin services are appropriate and aligned with Oregon regulations.
Completing this form does not commit you to a session.

Eligibility for Oregon Psilocybin Services

Oregon’s licensed psilocybin services are available to adults 21 years of age or older.

For safety and regulatory reasons, individuals are not eligible for services at this time if any of the following apply:
- Use of the prescription medication lithium within the past 30 days
- A diagnosis of active psychosis or current treatment for active psychosis
- Current thoughts of causing harm to yourself or others with an active plan
If none of the above apply to you, please continue.
Name*

First NameLast Name
Age*
Birth Date*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
All Psilocybin Administration sessions must take place at our licensed service center. Are you able to travel to our licensed service center in Eugene, Oregon for the psilocybin session?*

YesNoNot Sure Yet
What Brings You Here?

What brings you to explore psilocybin services at this time?(Select any that apply)
Microdosing or Low dose sessions

I am interested in trying a microdose or low dose sessionI am interested in regular microdosing or low dose sessionsI am interested in a high dose sessionI am interested in a high dose session with ongoing integration support
I am interested in a high dose session for:

DepressionGrief / LossMicrodosingAnxietyLonelinessSpiritualityPTSDTraumaPersonal GrowthJoy & CreativityPTSDWomen's CircleFinding Your Authentic SelfAddiction / RecoveryEnd of LifeOverall Health & Well BeingPersonal GrowthLife transitions or major decisionsSpiritual or existential explorationGaining perspective on patterns or habitsEmotional well-being or stressRecovery or re-evaluating my relationship with substancesCuriosityOther
If you chose 'other' please describe here:
Timeline and Readiness
Do you understand that preparation and integration sessions for large dose sessions are often conducted virtually, while the psilocybin session takes place in person at Emerald Valley Holistic?*

YesNo
When are you hoping to receive services?

As soon as possibleWithin 30 daysWithin the next 1-3 monthsWithin the next 3-6 monthsNot sure / UndecidedI'm exploring this as an option and would like to speak with someone
If you have specific dates you'd like to schedule please let us know them here:
Are your dates flexible?

YesSomewhatNo
Do you have any scheduling constraints we should be aware of?

NoYes
If you selected yes please let us know what scheduling constraints you have so we can best fit your needs
Support Levels & Package Options

You do not need to decide now. This section simply helps us understand what you’re exploring. (Select all that you are interested in) Selecting an option does not commit you to that package. Eligibility is reviewed first, and we’ll help clarify options if needed.
Psilocybin Session Options

Open Door SessionLegal psilocybin administration session with minimal follow-up supportEssential ClarityPrivate psilocybin session with light integration coachingNot sure I would like to know more
Psilocybin Session with Ongoing Integration Support Options

Clarity & Calm — 30 DaysShort-term integration coaching following a psilocybin sessionBreakthrough Perspective — 60 DaysDeeper integration support over a longer period of timeThe Next Chapter — 90 DaysExtended integration support during periods of transition or changeDeep Integration & Alignment — 6 MonthsLong-term integration coaching for ongoing reflection and supportNot sure yet, I would like to know more
Experience with psilocybin, or other psychedelics
Have you taken psilocybin or other psychedelics before?

NoYes once or twiceYes Multiple Times
Consent & Next Steps

Required acknowledgments
Please Select the Required Acknowledgments Below

I understand that Oregon psilocybin services are non-medical, non-diagnostic, and are not a substitute for medical or mental health treatmentI understand that submitting this form does not guarantee services and that eligibility will be confirmed by a licensed facilitator.
What Happens Next
Thank you for taking the first step. Once you submit this form, a member of our team will review your responses and reach out to you within 1-3 business days to discuss your eligibility, next steps, service options, and scheduling. We’re here to support you in choosing the experience that best fits your goals, timeline, and level of support.

If you’re ready to move forward or prefer to complete your intake and screening with us directly, we welcome you to reach out. Our team is happy to connect, answer questions, and help you take the next step toward a safe, supported psilocybin experience.

📧 Email: intake@emeraldvalleyholistic.com
📞 Phone/Text: (541) 321-8445
🌐 Website: emeraldvalleyholistic.com

We look forward to connecting with you and supporting you on your journey.
Should be Empty:

Intake Eligibility Form

What Brings You Here?

Timeline and Readiness

Support Levels & Package Options

Experience with psilocybin, or other psychedelics

Consent & Next Steps