• CRPS + Psilocybin Study Application

    Interest & Eligibility Form

  • Thank you for your interest in our pilot program exploring psilocybin-assisted therapy for Complex Regional Pain Syndrome (CRPS). This study is sponsored and run by Bendable Therapy with sessions provided by a licensed psilocybin service center in Bend, Oregon.

    Participants will receive a comprehensive psilocybin therapy experience at no cost. Expenses are covered, including:

    • All program fees for psilocybin services
    • Travel and lodging up to $1000
    • Gift cards for completing all survey questions

    What the Program Involves

    If accepted, you’ll complete the following:

    • A virtual screening and orientation session
    • Minimum of two preparation sessions with your facilitator, held virtually or in-person
    • One in-person psilocybin session (6–8 hours) at a licensed service center
    • Two integration sessions to help process your experience, held virtually or in-person
    • Online surveys at multiple points before and after the psilocybin session to evaluate progress

    Preparation, integration, and feedback interviews are held remotely on your schedule. Plan for 3 to 4 days in Bend, Oregon for the psilocybin session. 

    We are currently seeking a small number of individuals with CRPS to participate. Please complete the brief form below to determine initial eligibility and take the first step.

  • Format: (000) 000-0000.

  • Symptoms and Diagnosis History

    Please answer the following as best you can

  • Please note: if selected to proceed as a candidate, proof of CRPS diagnosis will be required. This can include any documentation from a provider or insurance listing a CRPS diagnosis or having your provider complete our verification form. This documentation will be requested when you are notified of being approved. 

  • Have you been diagnosed with Complex Regional Pain Syndrome (CRPS) Type 1?*
  • Who provided this diagnosis?
  • Is your pain limited to one limb or area?*
  • Which limb or area is affected (select all that apply):*
  • Has your CRPS persisted for 12 months or longer?*
  • Is CRPS pain your dominant pain condition (i.e., more severe than any other chronic pain you experience?)*
  • Can you clearly describe and rate your CRPS-related pain separately from any other pain conditions?*

  • Pain Severity

  • Use these descriptions as a guide in responding to the pain scales:

    1–3 = Mild (present but manageable; no major functional limits)
    4–6 = Moderate (interferes with focus or tasks; requires adjustments)
    7–8 = Severe (limits activities; hard to ignore)
    9–10 = Extreme (dominates attention; unable to function normally)

  •
  • Do you experience any of these symptoms:*
  • How does your CRPS-related pain affect your day-to-day functioning? (Select all that apply):*
  • Have you been diagnosed with any of the following conditions? (Select all that apply)*

  • Treatment History

  • Have you tried at least two different treatments for CRPS, from different classes or mechanisms (e.g., gabapentinoids, antidepressants, ketamine infusions, nerve blocks, spinal cord stimulator trials)?*
  • Please select treatments you have tried (select all that apply):*
  • Have your medications for CRPS or other chronic conditions been stable for at least the past 4 weeks?*
  • Do you currently use opiod medications?*
  • Has your opiod dosage been stable for the last month?*

  • Medical History

  • Do you currently have any of the following uncontrolled or significant medical conditions? (Select all that apply):*
  • Do you have any uncontrolled or significant medical conditions (cardiovascular, renal, hepatic, neurological)?
  • Have you ever had a heart attack, arrhythmia, heart failure, or been told you have a QTc interval over 470 ms?*
  • Do you have uncontrolled hypertension (blood pressure >160/100)?*
  • Do you have a history of seizures or epilepsy, including febrile seizures?*

  • Mental Health History

  • Have you been diagnosed with any of the following?*
  • Have you experienced active suicidal thoughts or attempts in the past 6 months?*

  • Study Logistics

  • Are you able to travel to Bend, Oregon for 3 to 4 days to complete the psilocybin session?*
  • Are you comfortable participating in a supervised psychedelic experience lasting 6–8 hours?*
  • Do you have prior experience with psychedelic substances?*
  • Do you have the capacity to provide informed consent?*
  • Are you willing and able to complete periodic online surveys regarding pain and mental health symptoms in a timely manner?*

  • Next Steps

    After reviewing your responses, someone from Bendable Therapy will contact you to schedule a screening conversation or provide more information.

    If you have questions, feel free to email us at ryan@bendabletherapy.org

     

    Data Sharing

    By submitting this application, you consent to Bendable Therapy reviewing the information you provide solely to determine your eligibility for this study. Your data will be stored securely, accessed only by staff directly involved in eligibility review, and will not be shared with third parties, sold, or used for marketing. You may request deletion of your data at any time, unless retention is required by law. Submission does not guarantee enrollment. By proceeding, you confirm that the information you provide is accurate and that you agree to these terms.

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