Emerald Valley Holistic Client Eligibility Form

  • Intake 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.

  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • 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?*

  • 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 a high dose session for:

  • 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?*
  • When are you hoping to receive services?
  • Are your dates flexible?
  • Do you have any scheduling constraints we should be aware of?

  • 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
  • Psilocybin Session with Ongoing Integration Support Options

  • Experience with psilocybin, or other psychedelics

  • Have you taken psilocybin or other psychedelics before?

  • Consent & Next Steps

    Required acknowledgments
  • Please Select the Required Acknowledgments Below

  • 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.

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