Clone of Private Sacred Mushroom Journey TEMPLATE

We are so excited to share this ceremony space with you!

We want to get some basic information to make sure that we are providing the most safe and supportive experience for you. All of the info on this form will be kept confidential.

We will have a 20 minute intake call on the phone once you've completed this form to connect and get to know one another.

Full Name

First NameLast Name

What is your age?

Your Phone Number

Format: (000) 000-0000.

Your Email Address

example@example.com

What ceremony are you interested in?

Emergency Contact Name

Emergency Contact Phone Number

What drew you to this experience? What motivation/intention do you bring?

Have you had psychedelic experiences before?

If so, please describe what psychedelics you've experienced, how often, and at what dosages.

Were these previous experiences helpful and considered positive? Or not helpful? Please explain.

Do you have any medical conditions, injuries, or physical limitations? Please list them here.

Please list any current medications by name that you are taking and what for.

Please list any current supplements/homeopathic/Ayurvedic/Chinese medicine remedies by name that you are taking.

Are you willing and able to discontinue any medications and supplements that are contraindicated with psilocybin before the retreat (more details to follow)?

How sensitive are you to things like caffeine, over the counter pain medication, and cough syrup?

Have you ever fainted?

Do you or anyone in your family have a history of epilepsy or seizures?

Do you or anyone in your family have a history of bi-polar disorder, schizophrenia, or psychotic episodes?

If the answer is yes to the above questions, please elaborate here.

Are there any needs you have for ceremony (physical or otherwise) that we need to be aware of?

Please give a thorough mental health overview, including traumas or issues you are currently working through.

Are you currently seeing a therapist or personal coach?

What spiritual practices do you engage with and how do these practices support you?

Please describe your support system for this ceremony (outside of everything included by Luminous Path in this process). This could include things like: therapist, life coach, chaplain, loved ones, etc.

Is there anything else you would like us to know that has not been addressed in this form?

Do you have any food allergies (especially chocolate since the mushrooms may be served in the form of chocolates) that we need to know about?